Introduction:
The maxillofacial region of human body has many essential functions of human body. This region is divided into three parts namely upper face, midface and lower face [1 -3]. The region above the supraorbital margins constitutes the upper third of the face and region between the supraorbital margins and the occlusal plane of the upper teeth constitutes the middle third of the face. The mandible with its dento-alveolar arch forms lower third of the face. It is composed of the several bones like frontal, nasal, ethmoid, zygomatic, maxillary and mandible. [1,2] Fractures of the upper third (upper face) includes fractures of the superior orbit and frontal sinus. Fractures of the middle third (mid face) include fractures of the nasal bones, naso-orbito-ethmoidal region, the zygomatico-maxillary complex, the maxilla, the medial, lateral, and inferior orbital walls and Le Fort I, II, and III fractures. Fractures of the lower third (mandible/lower-face) include mandibular fractures [4].
Maxillofacial traumatic injury (MFTI) encompasses injury to the face, jaws and related structures such as head [1,2]. It may be called as facial trauma in generic terms. Injury can range from involvement of skin, nerves, muscles and bone in isolation or in combination. It could be hard tissue injury with or without intact skin. Bony fractures in MFTI may range from simple nasal bone fracture to gross facial comminution. The complex maxillofacial trauma has the potential to cause facial disfigurement and difficulty in jaw movement [5-8]. In addition MFTI may be associated with brain injury, thoracic trauma and injury of nearby organs [6, 9, 10]. Hard tissue injuries include dental trauma, temporomandibular joint dislocation and bony maxillofacial simple/complex fracture. Mandible fracture is the most common fracture among all maxillofacial injuries followed by nasal, zygomatic and maxillary bones fracture[11].Clinical management of such injuries requires sincere coordination of maxillofacial and plastic surgeons. [1].
Facial trauma in addition to surgical treatment is accompanied by distressing psychological sequelae affecting the recovery and rehabilitation phase. [12] Structural damage can be in the form of nerve damage, facial disfigurement, scar on face, malocclusion. Traumatic dental injury can irreparably damage the adjacent supporting structures and soft tissues. It can lead to loss of the dental element. [13].
Most common cause for MFTI is road traffic injuries (60%) [14]. Other causes are interpersonal violence [14] fall injury and sports-related accidents [15-16]. Environmental factors, socioeconomic conditions, cultural reasons and traffic rules awareness are other contributory factors [14]. Maxillofacial injuries are one of the leading causes of death [14]. Epidemiologically the factors responsible for maxillofacial trauma are age, gender, geographic region, substance abuse, traffic legislation compliance/implementation, domestic violence and interpersonal violence [17].
Treatment modalities for MFTI include intermaxillary fixation (IMF), open reduction and internal fixation (ORIF) and open reduction and internal fixation with IMF. Different IMF techniques are IVY loops, Risdon’s method of wiring. Methods for open reduction include mini plates and trans-osseous wiring. Treatment of fracture varies according to age, type, status of teeth, severity of fracture, presence or absence of adjacent fractures and affordability of patients [18].
Good oral health plays crucial role in community participation including at work place (job performance), school and community performance (interpersonal interaction). Oral health requirements are major consumer of health expenditure and are the commonest health problem encountered worldwide. Locker has stated that oral conditions can have an impact on people’s living conditions positively and negatively [19].Oral health problems pose a negative impact on the quality of life at individual and social level. Poor oral health leads to reduced acceptance among public and withdrawal from social interaction [20]. Traebert had mentioned that it was pertinent to consider social and psychosocial factors also in addition to clinical conditions [21].
Maxillofacial trauma patient suffers from physical as well as psychological burden of the injury [12]. Physical injury includes facial disfigurement [12]. This may lead to withdrawal from social interaction (social loss). Children may experience stress by unsupportive peer behaviour and inability to participate in school activities such as play, sports and music [22, 23].
For quantification of MFTI, several scoring systems have been developed to evaluate severity level of maxillofacial traumas as a research tool for obtaining demographic information and predicting prognostic outcome. Some scores only evaluated functional parameters of the face with injury such as Maxillofacial Injury Severity Score (MFISS) and Mandible Injury Severity Score (MISS). Other scoring systems were made simple yet proven to have predictive value, such as Chinese Maxillofacial Trauma Registry, Analysis and Injury Severity Score System (CMISS) and Facial Injury Severity Score (FISS) [24].
FISS score was introduced by Bagheri in Journal Oral Maxillofacial Surgery 2006. In this scoring system, each fracture site and laceration on the face add points to obtain final score. Bagheri in his study [24] found correlation between FISS score and total operation cost. FISS score is a numerical value representing various facial areas with higher scores reflecting greater severity. This score has been shown to have relation between the cost of care and the patient's FISS score [24]. A study from Thorén observed that 25.2% of patients with facial trauma suffered from associated injuries requiring intervention by other specialties. It was assumed that higher FISS score with associated injuries increased the demand for special treatment by Orthopedic and Neurosurgeons [25]. The MFISS developed by Zhang et al. evaluates the injuries of the maxillofacial region. Its drawbacks are difficulty in evaluation of comminution and functional parameters.
FISS scoring systems was used because of its easy application, higher number of past studies for comparative purpose. [26] Among all the published classification and maxillofacial fracture scores, Facial Injury Severity Scale (FISS) score, introduced by Bagheri in 2006, is one of the applicable/used tool as per Literature which includes all components of maxilla, mandible, dentoalveolar components, nasorbital, zygomaticomaxillofacial complex and laceration of face more than 10 cm in length. The score was being used to assess the severity of the fracture in an easy way and for the purpose of precise accuracy in diagnosis of maxillofacial trauma fractures, prognosis, and estimating the length of stay. Assumption by Bagheri was that more severe the maxillofacial fracture, the longer the hospital stay needed [27].
MFTI leads to clinical condition requiring medical and surgical treatment. In additional it is a financial burden, has rehabilitation requirements and needs psychological / social support. Earlier studies focused on clinical course, treatment costs and other clinical parameters. None of the studies have focussed on assessment of social, psychological and rehabilitation requirements.
This study focused on relationship between FISS score as the clinical assessment of MFTI, as a tool for prognosis/morbidity prediction and a predictor for social and psychological impact.
Materials and Method
A prospective study was conducted from June 2018 to February 2021 on all cases of maxillofacial injury visiting a leading dental service provider of Punjab covering an area of 200sq Km. The study included 115 participants treated for MFTI. Data collection included demographics, etiology, MFTI clinical parameters, financial aspects and psychosocial loss. Clinical information pertaining to the maxillofacial injury and mode of treatment was obtained from the medical records of patient. Clinical classification was done as per FISS Scale; mandible was divided into condylar, coronoid, ramus, body, angle, symphysis and dento-alveolar regions. In the middle-third of the face, injuries were recorded as Le Fort, I, II, and III types, zygomatic complex, nasal bones, naso-orbito-ethmoidal complex and dento-alveolar fractures. The frontal sinus and orbital rim were recorded for upper face injuries. Patients were scored depending on the nature of their maxillofacial injuries using Facial Injury Severity Score (FISS). Etiological factors were classified as road traffic accidents, animal attack, slip and fall injury, assault, work injury, play and sports injuries. Social loss included hospital visit days; days spent dissociating oneself from social circle and community due to misery. Patients were interviewed at each follow-up visits for recording recovery and misery progress.
Duration of hospitalization included number of days from admission until discharge. Duration of surgery was counted as time taken for surgical procedure (in hours); from start of surgical procedure to its completion with rounding of to next higher hour. The data obtained was fed into spreadsheet and analysed using spreadsheet and SPSS using various scales and measures.
Results
Study included 115 maxillofacial trauma patients, 101 completed the study. Patients included 13(12.9%) of age group 11yrs-20yrs, 37(36.6%) were aged 21yrs-30yrs coinciding with the active age group in life, 32(31.7%) were aged 31yrs-40yrs, 10(9.9%) aged 41yrs-50yrs, 5(5%) aged 51yrs-60yrs, 4(4%) were above 61yrs age (Table 1). Male to Female ratio was 4:1. Unmarried were 33 (n=32.7%) and 68 (n=67.3%) patients were married.
| Table 1: Demographic characteristics of patients |
| |
n(%) |
Gender |
Male |
81(80%) |
Female |
20(20%) |
Marital status |
Unmarried |
33(32.7%) |
Married |
68(67.3%) |
Age (years) |
11-20 |
13(12.9%) |
21-30 |
37(36.6%) |
31-40 |
32(31.7%) |
41-50 |
10(9.9%) |
51-60 |
5(5%) |
61-70 |
2(2%) |
71-80 |
2(2%) |
FISS score was calculated among study patients by summation of all points. Average FISS score was 2.6.Most frequently involved bone was body/ramus / symphysis, condyle/coronoid process and zygomatico maxillary complex shown in Table 2.
| Table 2: FISS score |
Anatomic region |
Fracture type |
Points assigned |
No of Patient(n) |
Score |
Mandible |
Dentoalveolar |
1 |
6 |
3 |
Each fracture of body |
2 |
16 |
32 |
Each fracture of ramus |
2 |
23 |
46 |
Each fracture of symphysis |
2 |
36 |
72 |
Each fracture :condyle |
1 |
26 |
26 |
Each fracture :coronoid |
1 |
2 |
2 |
Mid Face |
Dentoalveolar |
1 |
8 |
4 |
Le fort I unilateral |
1 |
2 |
2 |
Le fort I bilateral |
2 |
1 |
1 |
Le fort II |
4 |
1 |
4 |
Le fort III |
6 |
0 |
0 |
Naso-Orbital ethmoid (NOE) |
3 |
0 |
0 |
Zygomatico Maxillary Complex (ZMC) |
1 |
32 |
32 |
Nasal |
1 |
0 |
0 |
Upper face |
Orbital roof/rim |
1 |
4 |
4 |
Displaced frontal sinus/bone fracture |
5 |
0 |
0 |
Non- displaced fracture |
1 |
1 |
1 |
Facial laceration |
Over 10 cm long |
1 |
32 |
38 |
NOTE: The FISS is the summation of the above in an individual patient |
190 |
267 |
FISS score among study patients ranged from 1 to7. FISS score was 2 for 39% patients and patients with FISS score 3 and 4 were 27% and 18% respectively. This was followed by FISS score 1 (13%) shown in Table 3.
| Table 3: Gender wise distribution of FISS score |
| |
|
Females |
|
Males |
|
FISS Score |
n (%) |
Females (n) |
Females (%) |
Males (n) |
Males (%) |
1 |
13% |
3 |
3% |
10 |
10% |
2 |
39% |
7 |
7% |
32 |
32% |
3 |
27% |
6 |
6% |
21 |
21% |
4 |
18% |
4 |
4% |
14 |
14% |
5 |
2% |
- |
- |
2 |
2% |
6 |
1% |
- |
- |
1 |
1% |
7 |
1% |
- |
- |
- |
- |
Total=101 |
100% |
20 |
20% |
81 |
81% |
Table 4 elaborates distribution of MFTI based on injury site. Mandibular fractures were observed in 69% MFTI cases of which 50% were mandibular only fractures. Mid-face only injuries were 12% and along with other injuries mid-face was involved in 38% the cases. There were no upper face injuries in isolation. Upper face was involved in 5% of the injuries. Laceration was observed in (32/101) 32% of the MFTI cases and 11% were laceration only cases. Laceration(s) were associated with (20/38) 52% for the Mid-face fractures, (2/5) 40% of upper face fracture and (14/69) 20% of Mandibular fractures.
| Table 4: Distribution of site of injury characteristic of patients |
| |
Mandibular n (%) |
Mid face n (%) |
Upper face n (%) |
Laceration n (%) |
Total(%) |
Mandibular |
50 (50%) |
6 (6%) |
3 (3%) |
14 (14%) |
69 (69%) |
Mid face |
6 (6%) |
12 (12%) |
3 (3%) |
20 (20%) |
38 (38%) |
Upper face |
3 (3%) |
3 (3%) |
0 |
2 (2%) |
5 (5%) |
Laceration |
4 (4%) |
20 (20%) |
2 (2%) |
11 (11%) |
32 (32%) |
Total |
69 (69%) |
38 (38%) |
5 (5%) |
32 (32%) |
101(100%) |
FISS score and etiology of MFTI were analysed and it was found that FISS score was found to be related to injury mode and was higher for activities with higher momentum (Table 5) Maximum FISS score was 7 with road traffic accidents (RTA) due to self negligence. Proportionally Maximum FISS score was higher in RTA cases. Average FISS score was similar for all categories. This meant that FISS score had higher spread for RTA cases. Standard Deviation was higher for Sports injuries. Statistically no significant difference (p=0.929) was observed using ANOVA between education level and FISS Score.
Patients were categorized based on their occupation (Table 5). Majority of patients were labours (28%). FISS score was then analysed on the basis of occupation profile. Minimum FISS score was 1 overall. Maximum FISS score was 4 with a SD of 1 among businessman, maximum FISS score was 5 with a SD of 1 among servicemen and Maximum FISS score was 7 with SD of 1 among labourers. Statistically significant difference (p=0.040) using ANOVA was observed between FISS score and occupation.
Patients (Table 5) were then categorised based on education levels. Majority (33%) of patients were matriculate, 38% had studied upto 8th Class. FISS score was analysed on the basis of education status. Statistically no significant difference (p=0.46) was observed using ANOVA between education level and FISS Score.
| Table 5: Distribution of FISS score among study patients based on etiology, occupation and education |
Distribution based on etiology |
ANOVA |
Etiology |
N |
Avg |
Min |
Max |
SD |
P value |
Sports |
3 |
3 |
1 |
4 |
2 |
0.929 |
At work |
1 |
3 |
3 |
3 |
|
Domestic |
11 |
2 |
1 |
4 |
1 |
Medical |
1 |
3 |
3 |
3 |
|
Misc |
1 |
2 |
2 |
2 |
|
RTA |
84 |
3 |
1 |
7 |
1 |
RTA Alcohol |
6 |
3 |
2 |
5 |
1 |
|
RTA Animal |
7 |
2 |
1 |
3 |
1 |
RTA Negligence other |
27 |
3 |
1 |
5 |
1 |
RTA Negligence Self |
44 |
3 |
1 |
7 |
1 |
Total |
101 |
3 |
1 |
7 |
1 |
|
Distribution based on Occupation |
Business |
11 |
2 |
1 |
4 |
1 |
0.040* |
Driver |
7 |
2 |
1 |
3 |
1 |
Farmer |
17 |
2 |
1 |
4 |
1 |
Housewife |
11 |
2 |
1 |
3 |
1 |
Labour |
28 |
3 |
1 |
7 |
1 |
Rag Picker |
1 |
3 |
3 |
3 |
NA |
Senior Citizen |
3 |
2 |
2 |
2 |
0 |
Service |
7 |
3 |
2 |
5 |
1 |
Student |
16 |
2 |
1 |
4 |
1 |
Total |
101 |
3 |
1 |
7 |
1 |
|
Distribution based on Education |
Illiterate |
1 |
3 |
3 |
3 |
NA |
0.46 |
2nd Class |
2 |
4 |
3 |
4 |
1 |
5th Class |
23 |
3 |
1 |
6 |
1 |
8th Class |
12 |
3 |
1 |
7 |
2 |
Matriculate |
33 |
2 |
1 |
5 |
1 |
12th Pass |
13 |
2 |
1 |
3 |
1 |
Graduates |
17 |
3 |
1 |
5 |
1 |
Overall |
101 |
2.62 |
1 |
7 |
1.13 |
|
| *=statistically significant |
Hospital stay duration was analysed (Table 6) among study patients. Majority 51%(n=52) were treated as outpatient, 50/101 required in-patient care either due to MFTI or due to associated injuries/health condition(s) like diabetes. All the patients with upper face injury required in-patient treatment. Mandibular MFTI patients (42/69) were in majority treated as out patents. Majority of Mid Face MFTI patients (26/38) required admissions.
Relationship between FISS score and duration of hospital stay was analysed. Average duration of stay was 2 days. Maximum duration of stay was 8 days and maximum stay duration decreased with increasing FISS score. There was no significant correlation (p=0.769) between duration of hospital stay and FISS score (Table 6 and Fig.1)
Duration of surgical procedure was analysed against the FISS score. Average duration of surgical procedure was 1 hr in patients with FISS score 1 and mean duration of treatment was 2 hrs in patients with FISS score ≥ 2. There was statistically significant (p=0.049) correlation between FISS score and duration of treatment with r = 0.196. Regression analysis was done and model predicted the outcome variable. The Coefficients showed regression equation: 1.43 + 0.133*(FISS score).
Hospital visits days were than correlated with FISS score. Patients with FISS score 1 had average 9 visits, FISS score 2 and 3 had average 11 visits, FISS score 7 had average 15 visits to hospital for treatment. Pearson’s Correlation analysis was performed between the two variables. Statistically significant (p= 0.009) correlation with (r= 0.258) was observed between FISS score and hospital visits for treatment. Regression model predicted hospital visit days with regression equation = 8.9 + 0.79*(FISS score) (Table 6 and Fig 2).
| Table 6: Distribution of FISS score on the basis of duration of hospital stay, surgical procedure and visits to hospital |
FISS score |
Distribution |
Duration of hospital stay |
Average duration of treatment (hrs) |
Average Trt visit days |
Count |
% |
Average |
Min |
Max |
Std Dev |
1 |
13 |
13 |
1 |
0 |
8 |
2 |
1 |
9 |
2 |
39 |
39 |
2 |
0 |
8 |
2 |
2 |
11 |
3 |
27 |
27 |
2 |
0 |
6 |
2 |
2 |
11 |
4 |
18 |
18 |
2 |
0 |
5 |
2 |
2 |
12 |
5 |
2 |
2 |
2 |
1 |
7 |
4 |
2 |
11 |
6 |
1 |
1 |
3 |
3 |
3 |
NA |
3 |
14 |
7 |
1 |
1 |
4 |
4 |
4 |
NA |
1 |
15 |
Total |
101 |
|
2 |
0 |
8 |
2 |
2 |
|
 |
Fig.1: Distribution of FISS score on the basis of duration of hospital stay |
 |
Fig.2: Distribution of FISS score on the basis of duration of surgical procedure and treatment visit days |
Table 7 shows Distribution of MFTI based on the etiology and site of injury: Laceration was observed in 35% of RTA, 33% of Sports injury and 9% of Domestic injuries. Mandibular fractures 67% (56/84) were most common due to Road Traffic Accidents (RTAs) followed by mid-face fractures 38% (32/84), lacerations 35% (29/84) and upper face fractures 6% (5/840). Domestic injury led to mandibular trauma in 73% (8/11) case followed by mid face trauma in 36% (4/11) patients and lacerations 9% (1/11). There was no upper face MFTI for domestic injury. Mandibular fractures were more common in sports injuries 67% (2/3) compared to other MFTI’s. Work related injuries and medical causes led mandibular fractures only. Violence led to multiple injuries in equal proportions.
Distribution of MFTI based on occupation: Mandibular MFTI was seen in all types of occupations. Upper face MFTI was found in labours, students and business class. Laceration was also found in most of the professions. No specific trend was observed and no predilection could be drawn.
Distribution of MFTI based on education level: Mandibular MFTI was observed irrespective of education level. Laceration was found in almost all the cases. No specific trend was observed and no predilection could be drawn.
| Table 7: Distribution of site of injury on the basis of etiology, occupation and education |
Distribution of study patients on the basis of etiology and site of injury |
Percentage of respective group |
| |
Mandibular (n) |
Mid face (n) |
Upper face (n) |
Laceration (n) |
Total (n) |
Mandibular % |
Mid face % |
Upper face % |
Laceration % |
RTA |
56 |
32 |
5 |
29 |
84 |
67% |
38% |
5% |
35% |
RTA Alcohol |
3 |
3 |
-- |
4 |
6 |
50% |
50% |
-- |
67% |
RTA Animal |
4 |
3 |
-- |
3 |
7 |
57% |
43% |
-- |
43% |
RTA Negligence other |
19 |
10 |
2 |
8 |
27 |
70% |
37% |
7% |
30% |
RTA Negligence Self |
30 |
16 |
3 |
14 |
44 |
68% |
36% |
7% |
32% |
Sports |
2 |
1 |
-- |
1 |
3 |
67% |
33% |
-- |
33% |
At work |
1 |
-- |
-- |
-- |
1 |
100% |
-- |
-- |
-- |
Domestic |
8 |
4 |
-- |
1 |
11 |
73% |
36% |
- |
9% |
Medical |
1 |
-- |
-- |
-- |
1 |
100% |
|
-- |
-- |
Attack by robbers |
1 |
1 |
-- |
1 |
1 |
100% |
100% |
|
100% |
Total |
69 |
38 |
5 |
32 |
101 |
68% |
38% |
5% |
32% |
Distribution of study patients on the basis of occupation |
| |
|
|
|
|
|
Percentage of respective group |
Occupation |
Mandibular (n) |
Mid face (n) |
Upper face (n) |
Laceration (n) |
Total (n) |
Mandibular % |
Mid face % |
Upper face % |
Laceration % |
Rag Picker |
1 |
-- |
-- |
-- |
1 |
100% |
-- |
-- |
-- |
Labour |
22 |
9 |
3 |
7 |
28 |
79% |
32% |
11% |
25% |
Farmer |
9 |
9 |
-- |
5 |
17 |
53% |
53% |
-- |
29% |
Student |
11 |
5 |
1 |
3 |
16 |
69% |
31% |
6% |
19% |
Service |
6 |
1 |
-- |
3 |
7 |
86% |
14% |
-- |
43% |
Business |
5 |
7 |
1 |
5 |
11 |
45% |
64% |
9% |
45% |
Driver |
5 |
2 |
-- |
5 |
7 |
71% |
29% |
-- |
71% |
Housewife |
7 |
5 |
-- |
4 |
11 |
64% |
45% |
-- |
36% |
Senior Citizen |
3 |
-- |
-- |
-- |
3 |
100% |
-- |
-- |
-- |
Total |
69 |
38 |
5 |
32 |
101 |
68% |
38% |
5% |
32% |
Distribution of study patients on the basis of Education level |
| |
|
|
|
|
|
Percentage of respective group |
Education |
Mandibular (n) |
Mid face (n) |
Upper face (n) |
Laceration (n) |
Total (n) |
Mandibular % |
Mid face % |
Upper face % |
Laceration % |
Illiterate |
1 |
-- |
-- |
-- |
1 |
100% |
-- |
-- |
-- |
2nd Class |
1 |
1 |
-- |
1 |
2 |
50% |
50% |
-- |
50% |
5th Class |
16 |
9 |
1 |
5 |
23 |
70% |
39% |
4% |
22% |
8th Class |
10 |
2 |
1 |
6 |
12 |
83% |
17% |
8% |
50% |
Matriculate |
19 |
16 |
2 |
10 |
33 |
58% |
48% |
6% |
30% |
12th Pass |
10 |
4 |
1 |
5 |
13 |
77% |
31% |
8% |
38% |
Graduates |
12 |
6 |
-- |
5 |
17 |
71% |
35% |
-- |
29% |
Total |
69 |
38 |
5 |
32 |
101 |
68% |
38% |
5% |
32% |
Delay in reporting to hospital was analysed with respect to occupation. Maximum delay was found among labourers (32 days) and mean was 4 days with a SD of 7 days. (Rag Picker being isolated case was excluded as outlier). Senior citizens had lowest maximum delay at 4 days. Excluding the outlier from analysis; it was found that there was no significant difference (p=0.749) between occupation and delay in reporting to hospital (Table 8).
Delay in reporting to hospital in days was analysed with respect to education level. Maximum delay was found to be higher in lesser educated with maximum standard deviation of 7 days. Average delay in reporting for specific treatment was lower in higher educated. Excluding the outlier from analysis; it was found that there was no significant difference (p=0.288) between education and delay in reporting to hospital (Table 8).
| Table 8: Distribution of delay in reporting to the hospital on the basis of occupation and education |
| |
N |
Mean |
Min |
Max |
SD |
P value |
Occupation |
|
Business |
11 |
4 |
0 |
11 |
4 |
.749 |
Driver |
7 |
5 |
1 |
10 |
4 |
Farmer |
17 |
3 |
0 |
13 |
4 |
Housewife |
11 |
2 |
0 |
10 |
3 |
Labour |
28 |
4 |
0 |
32 |
7 |
Rag Picker |
1 |
41 |
41 |
41 |
|
Senior Citizen |
3 |
3 |
1 |
4 |
2 |
Service |
7 |
4 |
0 |
13 |
6 |
Student |
16 |
2 |
0 |
10 |
2 |
Total |
101 |
4 |
0 |
41 |
6 |
Education |
|
Illiterate |
1 |
41 |
41 |
41 |
|
.288 |
2nd Class |
2 |
4 |
1 |
7 |
4 |
5th Class |
23 |
4 |
0 |
32 |
7 |
8th Class |
12 |
2 |
0 |
13 |
4 |
Matriculate |
33 |
3 |
0 |
23 |
5 |
12th Pass |
13 |
6 |
0 |
13 |
5 |
Graduates |
17 |
2 |
0 |
11 |
3 |
Total |
101 |
4 |
0 |
41 |
6 |
Patients were distributed on the basis of gap of days to report dental hospital after injury. Delay of reporting ranged from no delay i.e. 0 day to 41 days. Majority patients (31/101) reported after one day and 23/101 reported on the same say, 16/101 of them reported for treatment by 2nd day. It was observed then even patients with laceration took upto 13 days for specific treatment. Upper face MFTI cases reported within 2 days. This could be an incidental finding with fewer patients having upper face MFTI. No specific trend was observed (Table 9).
Number of days of admission required for treatment was analysed against the site of MFTI. No specific trend was observed for in-patient treatment with respect to site of injury (Table 9).
| Table 9: Distribution of delay to report hospital and duration of hospital stay based on the site of injury among study patients |
Days to report for specific treatment and site of injury among study patients |
Day |
Total (n) |
Mandibular (n) |
Mid face (n) |
Upper face (n) |
Laceration (n) |
0 |
23 |
18 |
7 |
- |
3 |
1 |
31 |
20 |
11 |
2 |
12 |
2 |
16 |
11 |
8 |
3 |
6 |
3 |
2 |
2 |
- |
- |
- |
4 |
5 |
3 |
2 |
- |
1 |
5 |
2 |
1 |
1 |
- |
1 |
6 |
1 |
- |
1 |
- |
- |
7 |
4 |
2 |
2 |
- |
2 |
8 |
3 |
- |
3 |
- |
2 |
10 |
5 |
4 |
1 |
- |
2 |
11 |
1 |
1 |
1 |
- |
1 |
13 |
5 |
4 |
1 |
- |
2 |
23 |
1 |
1 |
- |
- |
- |
32 |
1 |
1 |
- |
- |
- |
41 |
1 |
1 |
- |
- |
- |
Total |
101 |
69 |
38 |
5 |
32 |
Duration of hospital stay and site of injury among study patients |
Days |
n |
Mandibular (n) |
Mid face (n) |
Upper face (n) |
Laceration (n) |
0 |
52 |
42 |
12 |
- |
12 |
1 |
14 |
7 |
7 |
|
7 |
2 |
8 |
6 |
3 |
1 |
1 |
3 |
4 |
3 |
3 |
- |
2 |
4 |
8 |
4 |
4 |
2 |
2 |
5 |
10 |
4 |
7 |
2 |
6 |
6 |
1 |
1 |
- |
- |
- |
7 |
1 |
1 |
- |
- |
1 |
8 |
3 |
1 |
2 |
- |
1 |
Total |
101 |
69 |
38 |
5 |
32 |
Pre-reporting social loss in days was correlated with FISS score. Mean Pre reporting social loss was 3 days in patients with FISS score 3 and mean Pre-reporting social loss was 2 days in patients with FISS score 2 and mean social loss was 1 day in patients with FISS score 1. There was statistically no significant difference (p=0.193) using ANOVA between pre-reporting social loss and FISS score. Statistically there was no significant correlation (0.637) between FISS score and pre-reporting social loss (Table 10).
Social loss post-reporting/treatment start was also explored. Mean post reporting social loss was 36 days in patients with FISS score 4 and 35 days with FISS score 6 and 29 days with FISS score 2. Statistically significant difference between FISS score and post-reporting social loss (p=0.004) using ANOVA was observed. Statistically significant (p=0.001) correlation (r=0.351) between FISS score and post-reporting social loss was observed. Regression model statistically and significantly predicted the outcome with regression equation = 20.8+ 3.6*(FISS Score)(Table 10).
Total Social loss was also explored. Mean total social loss was 36 days in patients with FISS score 3 and 33 days with FISS score 5. Statistically significant difference between FISS score and total social loss (p=0.003) using ANOVA was observed (Table 10).
| Table 10: Distribution of FISS score and social loss of study patients |
FISS Score |
Minimum (in days) |
Maximum (in days) |
Mean (in days) |
SD (in days) |
N |
ANOVA (p value) |
Pre-Reporting Social Loss |
1 |
0 |
7 |
1 |
2 |
13 |
.193 |
2 |
0 |
12 |
2 |
4 |
39 |
3 |
0 |
30 |
3 |
7 |
27 |
4 |
0 |
6 |
1 |
2 |
18 |
5 |
0 |
0 |
0 |
0 |
2 |
6 |
1 |
1 |
1 |
- |
1 |
7 |
0 |
0 |
0 |
- |
1 |
Total |
0 |
30 |
2 |
5 |
101 |
|
Post-Reporting Social Loss |
1 |
5 |
42 |
19 |
13 |
13 |
.004* |
2 |
3 |
45 |
29 |
13 |
39 |
3 |
20 |
45 |
33 |
8 |
27 |
4 |
25 |
45 |
36 |
7 |
18 |
5 |
30 |
35 |
33 |
4 |
2 |
6 |
35 |
35 |
35 |
- |
1 |
7 |
32 |
32 |
32 |
- |
1 |
Total |
3 |
45 |
30 |
12 |
101 |
|
Total Social Loss |
1 |
5 |
49 |
20 |
14 |
13 |
.003* |
2 |
3 |
57 |
32 |
15 |
39 |
3 |
20 |
72 |
36 |
11 |
27 |
4 |
25 |
48 |
37 |
8 |
18 |
5 |
30 |
35 |
33 |
4 |
2 |
6 |
36 |
36 |
36 |
- |
1 |
7 |
32 |
32 |
32 |
- |
1 |
Total |
3 |
72 |
32 |
13 |
101 |
|
| *=statistically significant |
Total social loss of study patients was calculated on the basis of site of injury. Mean social loss was 36 days in mandible fracture patients having FISS score 4. Mean social loss was 35 days in mid-face fracture patients having FISS score 4. Mean social loss was 30 days in upper face fracture patients having FISS score 1 this indicates that morbidity is related with site of injury not only FISS score. Upper face fracture morbidity is more even with FISS score1 this shows social loss is not related with severity of score. Laceration was responsible for social loss of 28 days (Table 11). Social loss was analysed with respect to Site wise FISS score. For Mandibular MFTI minimum Social loss days increased with increasing FISS Score. Maximum Social Loss was same irrespective of FISS score for Mandible. Spread for social loss was higher for lower FISS score for mandible and for all the regions. Maximum Social loss increased with increasing FISS score for each region. Average loss days increased with FISS score for each region.
| Table 11: Distribution of FISS score and social loss of study patients based on the site of injury |
| |
|
|
Social loss in days |
SITE |
FISS score |
N |
Min |
Max |
Avg |
SD |
Mandible |
1 |
8 |
5 |
44 |
25 |
13 |
Mandible |
2 |
29 |
3 |
45 |
33 |
10 |
Mandible |
3 |
16 |
20 |
45 |
34 |
8 |
Mandible |
4 |
16 |
25 |
44 |
36 |
7 |
| |
Total |
69 |
3 |
45 |
33 |
9 |
Mid Face |
1 |
31 |
5 |
44 |
25 |
13 |
Mid Face |
2 |
6 |
7 |
45 |
31 |
13 |
Mid Face |
4 |
1 |
35 |
35 |
35 |
NA |
| |
Total |
38 |
5 |
45 |
26 |
13 |
Upper Face |
1 |
5 |
14 |
45 |
30 |
13 |
| |
Total |
5 |
14 |
45 |
30 |
13 |
Laceration |
1 |
26 |
5 |
45 |
28 |
12 |
Laceration |
2 |
6 |
20 |
35 |
29 |
5 |
| |
Total |
32 |
5 |
45 |
29 |
11 |
Discussion
Various factors identified for MFTI are road traffic accidents (RTA), sports injuries, slip injury, interpersonal violence similar to findings of earlier studies [28-31]. It was observed that 80% maxillofacial trauma patients were males and 20% were females, similar to earlier study findings [14,32] where 74.5% were males and 25.5% were females and 75.9% patients were males and 24.1% were females respectively. Males predilection could be attributed to more involvement in out-doors activities, sports and violent nature [33-35].
Road Traffic Accidents (RTA), worldwide is a known cause of mortality and morbidity in developing countries. It had been earlier observed that 62% of RTA involve riding on two wheeled motor vehicles [14]. It was observed that 84% patients suffered MFTI due to RTA similar to findings of other study [36]. Road traffic accidents among patients happened due to rash driving, alcohol intake, unawareness of traffic rules, road/driving condition, individual negligence and negligence of others. Stricter traffic rules enforcement and avoiding negligent behaviour can prevent such accidents. Sports related injury can be avoided by use of safety gears.
Most patients were aged between 21 to 30 years consistent with the findings of previous studies [33,37]. This age group is the most active stage of human life involved in different activities such as travelling for day-to-day activities, taking part in high risk exercises and sports, driving motor vehicles carelessly and most likely involved in violence. Thus this age group increases predilection for MFTI.
Mandible (69%) was a common site for MFTI similar to the finding of Jordan (74.4%) [29] and the second most common site was midface. In one study zygomatic complex fractures was common [38] and in another study naso-orbito-ethmoid complex fracture (67.46%) was most common to occur, while some recorded 66% mandible fractures cases. Another study recorded the zygomatic complex as the most affected structure (64%), followed by the naso-orbito-ethmoid region [39]. This variation could be attributed to varying geography, lifestyle, safety gear use, enforcement of traffic rules and geographic development status.
It was observed that FISS score showed more frequent involvement of mandible followed by zygomatic complex. Mandible angle, condyle and para-symphysis are weak anatomical structures increasing the risk for fractures. A blow on the chin is transferred to the condyle leading to condylar neck fracture. The parasymphysis is most prone to fracture due to long canine roots and angle is prone to fracture due to presence of mandibular third molars and abruptness between body of the mandible and ascending ramus. Injury to zygomatic complex occurs while avoiding injury to eye in case of a blow to mid face [38].
Appropriate Helmet provides protection from head injury and maxillofacial traumatic injury. National Traffic rules mandate helmet use while driving motorized two wheelers. Traffic rules are not strictly implemented in smaller cities and rural areas. This gets over added by unfavourable road conditions and unregulated traffic movement. Thus it could be inferred that unregulated traffic movement, unfavourable road conditions and non use of helmet are contributory factors. Such conditions predispose to higher frequency of MFTI due to road conditions but with lower severity as road condition restrict higher vehicular speed.
Occupationally Labourers had the highest MFTI. Being least literate /educated are unlikely to be acquainted with traffic rules and being economically lower possess two wheeled motor vehicles and try to save on safety gear. This group works harder struggling day night for bread and butter. Delayed reporting at work compels rash driving. Economically higher class and more literate people are likely to be using four wheeled vehicles thus lowering the possibility for MFTI. Occupation stress leads to preoccupied mind and consequential reduced alertness. It could thus be inferred that economic level over added by unawareness of traffic rules and further by occupation stress exaggerates the risk. While education was not found to be directly related to MFTI severity, it does indicate the possible occupation options and consequent risks.
MFTI leads to morbidity in terms of pain, discomfort, functional limitation(s), psychological stress, disfigurement, social cut-off. Delay in reporting to hospital prolongs such period. This also reduces disability free life/affects quality of life which may be temporary. It leads to compromise on activities of daily living and reduced productivity. One has to live lonelier in pain and misery due to disfigurement and functional compromise. Delay in reporting hospital for treatment was found irrespective of severity of trauma. Majority patients reported next day after injury. This was more so with associated facial laceration and difficulty in eating due to mandible fracture. Causes for delayed reporting can be poverty, financial constraints and life priorities. Occupation is another variable which affects health care service utilization. Healthcare service providers' timings clash with their earning hours. Sparing time for treatment and healthcare needs causes economic loss in addition to absenteeism from business hours. Affordability and scarcity of specialised health care services in the local area are other factors.
Early treatment is essential for early recovery. Delay in reporting to hospital can also be attributed to a delay in arranging money for treatment, convenient healthcare facility access, lack of time, unaware of consequences of injury and taking injury casually, fear of absenteeism from work. Maximum delay in reporting for specialised treatment was observed among lesser educated. Majority of patients (31/101) reported after one day and 4/101 reported after one week. Most frequent reasons of early reporting for treatment were facial aesthetics and functional difficulty such as difficulty in eating.
FISS score was calculated and compared with findings from earlier studies. It was additionally analysed as a predictor for health and rehabilitation needs [26] .Our mean FISS score was 2.6± 1.0 with a range of 1 to 7 similar to other studies (2.73±1.163) with a range of 1 to 8 [40] . Yamamoto et al in Japan showed FISS score ranged from 1 to 12 with an average of 1.52±1.40 [41] .The average FISS Score was 3.00 ± 1.43 with a minimum value of 1 to a maximum score of 6 and the most of the Patients had FISS 2 (25.8%) [42]. Results of research conducted by Bangun [43] showed that the average FISS was 3.37 ± 1.9 with minimum value 1 and maximum 9, and most frequent finding was FISS 2 (24,7%) [18] .
Bagheri [24] found an average FISS score as 4.4 and maximal score as 13. Such variation can be attributed to geographic variation, local traffic /driving conditions [44]. In one study most maxillofacial traumas were due to low velocity [44]. Poor road driving conditions lead to slower vehicular speed and thus lower FISS score. Lower score can also be explained considering that; patients with higher FISS score, were likely to have associated additional injuries like head injury or limbic fractures. Lower FISS score in the current study could be attributed to poor road driving conditions and higher FISS score patients being taken to multi-speciality trauma hospitals for associated life threatening conditions. Thus they are likely to be taken to medical centres (rather than specialised dental centres), as other injuries could be life threatening. Such studies are mostly conducted at specialised dental treatment facilities. Many of the MFTI patients are likely to be missed for inclusion in such studies due to significant morbidity / mortality due to other injuries like head injuries.
Significant difference (p=0.04) was observed between FISS score and occupation of maxillofacial trauma patients. It was higher for occupational activities with higher momentum
Duration of hospital stay was analysed. Majority 51% (n=52) were treated as outpatients. Shorter one day stay was required in 14% patients to observe for possible immediate complications. Mid face and upper face fracture patients required comparatively longer stay for injectable antibiotics, blood glucose levels stabilisation, repeated dressing requirement and complication monitoring. Duration of stay also depends on other factors such as the general medical condition of patient, severity of trauma and affordability for specialised treatment. Facial laceration was not associated with hospital stay.
It was observed that average duration of stay was 2 days in contrast to average days of stay of 11.93 ranging in a study by Suwal et al [40] and less than 5 days by study by Park et al [45]. One study by Kesuma in Indonesia showed mean duration of hospital stay 3.37 ± 1,9, with minimum value 1 and maximum value 9 [40]. A study by Tambayong et al[27] found that the FISS score serves as a good predictor for the length of stay for maxillofacial trauma patients and FISS scores correlated significantly (r = 0.718) with length of stay. A study by Bangun [44] did not support the FISS scoring system as a determinant variable for functional disabilities quantification. No significant correlation (p=0.769) between duration of hospital stay and FISS score was observed in the current study in contradiction to findings of Bagheri et al [24]. It is possible that FISS score is a predictor for hospital stay for patients with higher Score. Bocchialini and Castellani [46] found that an increase of FISS score by 1 mark was associated with the increase in hospitalization duration of 12% (1.44 days). Siregar et al [47] reported a more pronounced relationship between FISS score and length of hospital stay. Brekhlichuk et al found no relationship between FISS score and with duration of hospitalization [48].
Significant relationship (p=0.049) was found between surgical procedure duration and FISS score. Low correlation observed indicates that FISS is a weak predictor for surgical procedure duration. MFTI treatment involves multiple visits for irrigation, dressings and radiographic investigations for healing of fracture site(s). Hospital visit days were found to be significantly (p=0.0009) related to FISS score.
Site of injury is an important decision marker for mode of treatment. Treatment approaches included intermaxillary fixation (IMF), open reduction and internal fixation (ORIF), ORIF + intermaxillary fixation (IMF) and conservative approach. ORIF was performed on 14%, 49% were treated with ORIF + IMF and 28% were treated with IMF. This was as per needs and financial status of patients. Most frequent mode of treatment was ORIF & IMF. Such a procedure leads to limited oral functions. Patients are not able to open their mouth for 6 weeks. They are unable to eat, speak, communicate and face difficulty in oral care. No correlation was found between FISS score and mode of treatment. While the FISS score has some relation of severity, but was unrelated to treatment modality. Treatment modality used relates to treatment expenses likely to be incurred.
Social loss was quantified and split into two parts: before availing treatment and after starting treatment (Post reporting social loss). There was no significant difference in FISS score and pre-reporting social loss. Standard deviation for pre-treatment social loss had wide variation. This may mean that there is a need to identify factors which lead to variation in pre-treatment delay there by adding to morbidity and compromised quality of life for that period. Identification of such factors may help in reduction of such loss and also public health planning. Significant difference was found (p=.003) between total/combined (Pre and post reporting) social loss and FISS score. Average combined social loss increased with FISS score. Post reporting social loss was found to be significantly related to FISS Score with r=0.351. Average post reporting social loss increased with FISS. This signifies that variation in combined social loss is largely due to the post reporting period. Standard deviation for social loss days was higher with lower FISS Score. It can be concluded that FISS score is a weak predictor or there are factors other than clinical assessment with FISS score that cause variation in social loss duration. Facial laceration patients had an average 29 days of social loss. Facial laceration itself is not related to functional limitation. This indicates that social loss is related to factors other than clinical assessment with FISS score.
Related factors highlighted and identified predictors in the study include:
- Injury site as related to available treatment option and thus respective financial burden;
- Education related to occupation. Occupation related to predisposing factors like driving, sport etc. Predisposing factors related to severity of MFTI;
- FISS score as indicative of surgical procedure duration, hospital visits required, social loss;
- Occupation leading to possible higher FISS score.
The following shall require further work for quantification/better quantification:
- Education level as indicative predictor for trauma severity;
- Occupation as indicative predictor for trauma severity;
- Pre-reporting delay period prediction and consequent social and financial loss;
- Injury site in relation to occupation;
- Parameters to predict hospital stay, like injury site;
- Scoring which specifically includes aesthetic related injury for morbidity duration and social loss;
- Financial background in relation to morbidity duration and compromise quality of life days.
Conclusion
FISS score alone cannot predict rehabilitation requirements for the maxillofacial trauma patients. There is a need for various rehabilitation modalities in addition to clinical therapy. Large majority healthcare providers focus primarily on the clinical component of treatment. Psychosocial rehabilitation largely suffers on account of ignorance among patients and even among clinical treatment providers. Study also indicates that there is need for better and holistic assessment scale as predictor for holistic treatment and rehabilitation requirements. It can thus be interpreted that there is a need for a comprehensive scale for assessing the severity of maxillofacial trauma and be able to predict financial burden for clinical treatment and psychological treatment, possible morbidity and rehabilitation requirements.
Returning to normal life after maxillofacial trauma is influenced by clinical, psychological and socioeconomic variables. Recovery and rehabilitation from MFTI is a multi-modality process. It includes/depends on clinical recovery, aesthetic recovery (residual scarring), function recovery, financial loss, job/earning loss (or education loss or business loss etc as applicable), psychosocial trauma. Post clinical recovery some of the factors include aesthetic recovery, retrospective recovery of financial loss, psychological impact. Being social animal’s sometimes psychological stress of mockery by colleagues can have a longer lasting impact. Such recovery depends on the emotional maturity of an individual which varies from person to person. Understanding MFTI for severity, clinical treatments costs, allied treatment modalities and rehabilitation requirements become important for long term public health planning and for medicare / health insurance plans.
Question arises as to whose responsibility is to ensure psychosocial rehabilitation by providing 1. Guidance to Patient/family, 2. Making it available, 3. Incorporating it into reimbursement plans like medclaim/medicare plans? Do we have customised medicare/mediclaim plans considering risk, financial loss, and holistic recovery requirement? What should be the role of public health experts to make ends meet? Even if factored, how to quantify such requirements. Further research shall be required in search for answer to above.
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