Fractures of the midface in the orbito-malar region may involve the floor and, to a lesser extent, the lateral wall of the orbit. Assuming therefore that we are asked which is one of the most frequent complications of the floor of the orbit, two complications should always be highlighted that may indicate surgical treatment, even urgent: diplopia, due to dislocation of the inferior rectus muscle to the underlying maxillary sinus (and even its entrapment); and enophthalmos, which may cause other associated complications in the medium and long term, such as superior palpebral pseudo-ptosis due to loss of orbital volume (option 4 correct). Temporomandibular ankylosis is not considered because, although relatively close to the orbital cavity, it is not part of the orbito-malar complex (option 1 discarded). Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity (option 2 discarded). Naso-ethmoidal fractures are included in midface fractures, but the bones of the nose are located more anteriorly to the medial orbital rim, and therefore outside the orbit (option 3 discarded).

Fractures of the midface in the orbito-malar region may involve the floor and, to a lesser extent, the lateral wall of the orbit. Assuming therefore that we are asked which is one of the most frequent complications of the floor of the orbit, two complications should always be highlighted that may indicate surgical treatment, even urgent: diplopia, due to dislocation of the inferior rectus muscle to the underlying maxillary sinus (and even its entrapment); and enophthalmos, which may cause other associated complications in the medium and long term, such as superior palpebral pseudo-ptosis due to loss of orbital volume ([HIDDEN]). Temporomandibular ankylosis is not considered because, although relatively close to the orbital cavity, it is not part of the orbito-malar complex ([HIDDEN]). Involvement of the maxilla can lead to dental malocclusion, but usually occurs in fractures located lower than the orbital cavity ([HIDDEN]). Naso-ethmoidal fractures are included in midface fractures, but the bones of the nose are located more anteriorly to the medial orbital rim, and therefore outside the orbit ([HIDDEN]).

20-year-old patient who comes to the emergency department after suffering a bicycle accident with facial trauma. A cranial CT scan was performed showing a fracture of the middle third of the face involving the orbito-malar region. One of the most frequent complications of this type of fracture is:

Panfacial fractures: analysis of 33 cases treated late.

The aim of this retrospective study was to analyze the characteristics of delayed panfacial fractures and evaluate treatment results. Thirty-three patients with delayed panfacial fractures were treated in the Maxillofacial Trauma Center of Peking University, School and Hospital of Stomatology between 1998 and 2004. Each patient was examined by computed tomography (CT) scans before operation. For those who had no severe opening restriction, dental impressions were taken to fabricate dental casts. For those with severely comminuted fractures, 3-dimensional (3D) models of the facial skeleton were used. Re-establishing the continuity of the mandible was the first step and then used as a platform to reconstruct the maxillary fractures via maxillomandibular fixation after Le Fort I osteotomy. The third step was to restore the mid- and upper-facial width and projection by coronal approach to expose the zygomatic complex and frontal bone/sinus and/or naso-orbito-ethmoid (NOE) fractures. There were 3 types of mandibular fractures that affected the treatment plan: 1) type I, mandibular body/symphysis fracture(s) (17/33, 51.52%); 2) type II, mandibular angle and/or condylar fracture(s) (6/33, 18.18%); and 3) type III, both mandibular body/symphysis and angle/condylar fractures (10/33, 30.30%). Fourteen cases were associated with NOE fractures (42.42%) and 3 cases had frontal sinus fractures (9.1%). Twelve cases had enophthalmos (36.36%) and 3 lost 1 eyeball. The order of treatment was dependent on the mandibular fracture type. For type I fractures, reconstructing the mandibular arch was the first step. For type II fractures, repairing the angle, ascending rami, and condylar areas was the first step. For type III fractures, when both mandibular height and arch were disrupted, freeing the malunited angle or condyle was the first step before restoring the mandibular arch form. Reconstruction of the mandibular height and projection was then carried out. For all 3 types, the second step was to restore the mid- and upper facial width and projection by reducing the zygomatic complex and frontal bone/sinus or NOE fractures. Maxillary fixation across the Le Fort I level was the last step. Le Fort I osteotomy was used for all 33 cases. Bone grafts and soft tissue suspension also were used. Twenty-one cases (63.64%) had good results, 7 (21.21%) cases were acceptable, and 5 (15.15%) were not good. There were 7 cases (21.21%) that still had soft tissue problems that needed secondary operations. Reconstruction of the mandible first with Le Fort I osteotomy is a good way to treat delayed panfacial fractures. Computed tomography and 3D CT, model surgery, and occasionally 3D models are necessary aids for diagnosis and treatment. Soft tissue problems, including lacerations and asymmetries, were often the factors that caused an unfavorable outcome.

Etiology, incidence and patterns of mid-face fractures and associated ocular injuries.

A prospective study on mid-face fractures was carried out in the Department of Oral and Maxillofacial Surgery at College of Dentistry, Indore, from August 2007 to September 2009 to analyze etiology, incidence and patterns of midface fractures and associated ocular injuries. Two hundred patients were included in this study, amongst those who reported to the Department of OMFS, College of Dentistry, Indore. After confirmed diagnosis of mid face fracture all the patients were stratified according to age, sex, cause of the accident, influence of alcohol, location, type of fractures and associated ocular injuries. The study included 200 patients with a mean age of 29.6 years. The most frequently injured patients belonged to the 21-30 year-old age group. The male predilection was 76 %. Road traffic accident was the most common causative factor (64 %), followed by assault (21 %), cases of fall (9.5 %) and other causes (5.5 %). The most common fracture in this study was found to be zygomatic complex fractures (62.5 %) (more in the age group of 21-30 years). This was followed by Lefort II fractures (23 %), multiple fractures (10 %) and Lefort I fractures (6 %), Lefort III fractures (4.5 %) and Naso-ethmoidal fractures (4 %) in descending order. 84.5 % subjects were having ocular involvement. Subconjunctival hemorrhage was present mostly in 83.5 % followed by remaining as corneal injury 15 %, reduced acuity 11.5 %, diplopia 10.5 %, enophthalmos 8.5 %, telecanthus 5 %, hyphema 3.5 %, blindness 3 % and proptosis 0.5 %. Zygomatic complex fractures were the most frequent type of injury that was complicated by blindness or a serious eye injury (61 %). Collection of data regarding the epidemiology of maxillofacial fractures is important because it may assist healthcare providers to provide necessary information for the development and evaluation of preventive measures. Ocular injuries should have an early ophthalmological examination at the time of trauma to detect any kind of ocular dysfunction.

Maxillofacial Trauma in Geriatric Population.

The worldwide population is increasingly aging. Maxillofacial fractures of the geriatric population have been increased. Evaluation of the demographic variables, causes and the patterns of maxillofacial traumas in the elderly population is the main aim of this study. Seven hundred thirteen maxillofacial tomography images which were scanned between 2010 and 2019 were evaluated. Data from 50 patients aged 65 years old and/or older, who were treated for maxillofacial fracture at the Department of Otorhinolaryngology, Gaziantep University, were retrospectively analyzed. Two groups were created according to the facial fracture pattern. Facial fractures were reclassified into 2 groups; mandibula, orbital, zygomaticomaxillary complex group fractures and the other group of frontal, naso-orbito-ethmoid fractures and were used as a comparison. The mean age of the patients was 72.5 (min 65- max 93). The gender distribution was 17 females (34%) and 33 males (66%). The most common fractured bone was the nasal bone and the least one is the frontal bone. Approximately one-quarter of 50 fractures were seen in 70 to 79 years old. Falling is more common in females and men are more prone to work-related accidents than home-related accidents. Facial fractures in the elderly often seen in midface location. Falling is the common etiology of facial fracture in all genders at elderly. However, male dominance is seen in other etiological factors. Additional diseases in the elderly seem to increase the severity of facial fracture.

Ophthalmic Complications in Maxillofacial Trauma: A Prospective Study.

To determine the incidence and types of ophthalmic complications associated with maxillofacial trauma over a period of 24 months. An institutional prospective study was conducted on 62 patients presenting with maxillofacial trauma to study the correlation between facial trauma and ophthalmic complications. Road traffic accidents were reported to be the primary etiologic factor for most trauma cases studied. Zygomaticomaxillary complex (ZMC) fracture was associated with more ophthalmic complications while fractures involving the orbital rims and walls were associated with severe complications. Maxillofacial trauma, particularly those associated with midface, including ZMC fracture, Le Fort II, Le Fort III, and naso-orbito-ethmoidal fractures, can commonly cause ophthalmic complications and blindness in rare cases. Hence, every patient with maxillofacial trauma should undergo an ophthalmic examination and should be placed under close observation for necessary treatment when required.

Late sequelae after high midface trauma.

The upper midface area comprises mainly the naso-orbito-ethmoidal (NOE) region which plays a paramount role in facial expression. Fractures of this area often result in neglected bony defects in the fragile periorbital region with major secondary impairments such as traumatic telecanthus, orbital dystopia, and/or enophthalmos. Permanent cranial nerve deficits also can occur as the result of post-traumatic/post-operative sequelae. Seventy-one patients (age range 7-78 years) with severe high midface trauma, treated from January 1989 to December 1996, were reviewed with a minimum follow-up of 2 years. The patient population has been distributed according to the fracture type in three groups: Group 1 (n = 35): Isolated NOE with/without associated central midface injury; Group 2 (n = 22): NOE associated with craniofacial injury and Group 3 (n = 14): NOE associated with orbital displacement. The estimated post-surgical parameters included qualitative and quantitative data from the long-term clinical evaluation. Persistent headache and/or concentration difficulties were mainly noted in Group 1. Smell reduction or anosmia was reported mainly in Group 2. Deficits of the trigeminal and/or the facial nerve were found in Group 3. Enophthalmos and/or telecanthus were predominantly seen with injuries associated with orbital displacement.

Nasoorbitoethmoid fractures in a tertiary care hospital of eastern India: A prospective study.

The purpose of this study was to report on the pattern of occurrence of nasoorbitoethmoid (NOE) fractures in Odisha and the various factors that influence their distribution. The study period was from January 1, 2016 to December 15, 2017. After approval from the Institutional Ethics Committee, all patients diagnosed with naso-orbito-ethmoid fractures reporting to the department of OMFS and Level-1 trauma centers were included in the study. Sociodemographic data along with the etiology and type of fracture were mentioned. Associated injuries to other body parts were noted. Open reduction was possible only in five cases of NOE fractures. The treatment plan including the operative approach and postoperative results was evaluated. A total of 1192 patients with facial fracture were seen, of which 52 (4.36%) patients had NOE fractures. Males far outnumbered females in a ratio of 9:1. Thirty-three patients (63.46%) had unilateral NOE fracture, while the rest 19 (36.54%) had bilateral NOE fracture. Sixteen (30.76%) cases were classified as Type I, 35 (67.30%) as Type II, and 1 (1.92%) as Type III. Road traffic accidents were the most common cause of NOE fractures (69%), followed by fall (17%) and assault (10%). The most common neurological injury to be associated with NOE fractures was pneumocephalus (29%), followed by diffuse axonal injury (8%). Telecanthus (100%) was found to be the primary clinical feature in patients of NOE fracture, followed by a depressed nasal bridge (92%). Fracture of the nasal bone was invariably associated with NOE fracture. Complications observed due to untreated NOE fractures included a shortened and retruded nose, shortened palpebral fissures, telecanthus, and enophthalmos. Contemporary management of NOE complex fractures demands precise diagnosis and immediate surgical management with anatomic reduction and rigid fixation of the involved bone segments. With an improvement in socioeconomic status and increased awareness among maxillofacial surgeons, hopefully, a greater number of NOE fracture patients will avail the benefits of open reduction in future.

Fractures in the Maxillofacial Region: A Four Year Retrospective Study.

The incidence of maxillofacial injuries is on the rise due to motor vehicle accidents and increased incidence of violence in recent times. The aim of this retrospective study was to determine the incidence, aetiology, the pattern of fractures, their management with open reduction and internal fixation (ORIF) and complications, if any. A retrospective analysis of 621 fractures in 361 patients managed by ORIF over a four year period was carried out. The average age of patients was 24.3 years with a male to female ratio of 21.2:1. Panfacial fractures comprised 4.7%, frontal bone fractures 8.9%, orbital fractures 0.7%, naso-orbito-ethmoid complex (NOE) fractures 0.7%, zygomatic complex fractures 23.5%, fracture maxilla 11.5% and mandibular fractures 52.2% of all facial fractures. All the cases were successfully managed by ORIF under general anaesthesia (GA). Complications were noticed in 6.8% of cases in the form of reactive implants in 3.6%, deranged occlusion in 1% and infection at operated site in 1% cases which were managed satisfactorily. The findings of this study reveal sharp annual increase in the number of cases of maxillofacial trauma. Road traffic accidents (RTA) were the commonest cause and the age group most affected was between 20-25 years. ORIF of these fractures was chosen for its obvious advantages of direct anatomical reduction, early return to function and minimal complications.

Facial and Orbital Fractures: A Fifteen Years Retrospective Evaluation of North East Sicily Treated Patients.

Orbital fractures are classified as diseases usually related to common midface trauma. It represents the most challenging treatment due to the complex anatomy, physiology, and aesthetic role. A midface trauma involves also the zygomatic complex and the nose, however the orbit fracture seems to be a more frequent disease due to its anatomical features. The purpose of this work is to retrospectively evaluate and record the frequency of the midfacial traumas and orbital fractures observed in the North Eastern Sicily. The results of the present data may be useful for the clinicians in order to recognize the kind of fracture just from the first general visit having a quick diagnosis and management. In the years between 2001 and 2016, about 1200 patients with midfacial trauma and about 100 patients involving the orbital floor have been evaluated. All those patients underwent the surgical fracture reduction and a CT scan follow up control at one month, three months, six months and one year. Data showed high percentage of orbital floor, nose and mandibular body and ramus fractures; moreover the most frequent causes of fractures seem to be related to motor vehicle accident, followed by assaults, work and fall. The results have highlighted the changing trends in the causes of facial injuries, particularly the increasing incidence of assaults and the falling incidence of motor vehicle accidents in developed countries. The quick diagnosis and management proved fundamental for the successful treatment. Clinicians should be able to recognize the first symptoms in order to avoid possible complications.

Analysis of symptoms according to areas of orbital floor in orbital inferior wall fractures.

A considerable number of patients experiencing facial trauma are diagnosed with blowout fracture. Preoperative computed tomographic scan is often different from the actual surgical area. This study is restricted to orbital floor fracture. This study is expected to help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. From March 2005 to September 2013, a total of 150 cases of orbital floor fracture surgeries have been analyzed. This study analyzed the preoperative symptoms at the certain fractured area of orbital floor, at the aspects of sagittal view of computed tomography, which is sectioned into anterior one-third, middle one-third, posterior one-third, and mixed types. Symptoms for analysis are diplopia, extraocular movement limitation, enophthalmos and other combined facial bone fractures, and the like. Fracture areas of orbital floor are 21 cases (14%) of anterior one-third, 47 cases (31%) of middle one-third, 7 cases (5%) of posterior one-third, and 75 cases (50%) of the mixed. Frequency of diplopia was 0 case, 24 cases (42.1%), 4 cases (7.0%), and 29 cases (50.9%), respectively. In the case of extraocular movement limitation, 0 case, 15 cases (39.5%), 2 cases (5.3%), and 21 cases (55.2%) were found, respectively. In the case of enophthalmos, 0 case, 5 cases (16.7%), 7 cases (23.3%), and 18 cases (60.0%) were found, respectively. The most commonly associated other facial bone fractures were nasal bone fractures. In the case of blowout fracture, diplopia, extraocular movement limitation, enophthalmos, and other symptoms are checked through physical examination. This study would help speculating fracture site and making surgical plans according to symptoms of periorbital trauma.

[Secondary reconstruction of posttraumatic orbital deformities with canthus dislocation].

To explore the secondary surgical reconstruction for orbital bone deformities accompanied with canthus dislocation after trauma. From June 1998 to July 2007, 37 patients with secondary orbital bone fracture deformity accompanied with medial or lateral canthal ligament dislocation posttraumatically were treated, among whom there were 22 males and 15 females, aged 13-46 years old (21 on average). There were 29 cases of traffic accident, 6 of boxing injury and 2 of beating injury by sticks. The latest reconstruction was performed on these 37 cases during 3 months to 8 years after injuries. There were 11 cases of orbital maxillary zygoma (OMZ) fracture, 15 of naso-orbito-ethmoid (NOE) fracture, 8 of OMZ and NOE fracture and 3 of frontal fracture. There were 31 patients who were reconstructed for the first time and 6 for the second time. Typical bicoronal and subciliary incisions and intra-oral approach were employed to expose all the fractured sites. According to the fractured position and the degree of deformity and dislocation, the orbito-zygomatic fracture was repositioned after osteotomy and rigid fixation, or the healed fragments were trimmed with a burr and the depressed fragments were filled with autogenous bone such as ilium, cranial outer table or Medpor in order to reconstruct orbital wall framework; the orbital walls were repaired to correct the enophthalmos with autogenous bone or Medpor after the herniated orbital contents were released. The medial canthal ligament was anchored superior-posteriorly to the lacrimal fossa with transnasal wires fixation or fixed with titanium miniplates and nails. The 36 patients' incisions obtained healing by first intention after the operation, and 1 case failed because of wound infection from maxillary sinusitis. There were 24 patients who were cured successfully with facial appearance and function improved significantly. During the follow-up for 3-6 months, no complication was found such as dislocation of the implant, rejection and infection. Two patients still showed slight enophthalmos while 3 patients with canthus dislocation regained improved appearances but not satisfactory. At 6 months after operation, the CT scan conducted in 3 patients with autogenous bone and Medpor grafting showed all fractures were fixed rigidly. Surgical reduction combined with bone grafting is a satisfactory method for the correction of secondary orbital bone deformity, and the repair of canthus dislocation and correction of enophthalmos should be considered at the same time. An ideal result could be achieved only through all-round consideration and comprehensive treatment.

Occurrence of mandibulofacial injuries presenting to the otorhinolaryngology and head & neck surgery department.

Trauma is the fourth major cause of mortality in the Western countries, of which approximately one half involve maxillofacial injury. Statistics reported by emergency room officials show motor vehicles cause many of the injuries and deaths that occur in Iran. Having completed a retrospective descriptive study of 200 patients who experienced maxillofacial trauma, the authors report its occurrence with respect to age, sex, trauma type, and site of injury so as to evaluate the operational functionality of the Department of Otolaryngology and Head & Neck Surgery of Hazrat-e Rasoul Akram Hospital from 2000 to 2004. Mandibular fractures (36.2%) occurred in the subsequently listed sites and at the specified frequencies: mandibular angle (9.7%), mandible body (6.9%), parasymphysis, ramus and subcondyle at 5.6% each, and symphysis at 2.8%. No condylar fractures were reported. Frontal bone fracture was observed in 9.7% of the patients with eye globe injury occurring simultaneously in 8.3% of corresponding cases. Orbital fracture (63.9%) also occurred in various cases as follows: orbital floor 39%, lateral rim 24%, inferior rim 22%, medial wall 11%, and the superior rim and orbital roof at 2% each. Motor vehicle accidents were the most common causes of trauma (42%). The most common fracture was in the zygoma (43%) with 8.3% of them being orbital injury. Fractures of mandibular bones (36.2%) and the maxilla (33%) were the most commonly seen in trauma occurring to the maxillomandibular region.

[Clinical study of mandibular condyle injury].

Mandibular condyle fractures develop frequently and show the variable type of injury and complication. New opinions have emerged from recent investigation into condylar fractures. The author investigated 246 patients with condylar fractures who visited SNUDH from January 1980 to August, 1988, 8. with regard to clinical and treatment aspects, area and displacement of fractures, associated teeth injury and other body injury, complications. At last I have got the following results. 1. The incidence to condylar fractures in a series of 765 mandibular fractures may be as high as 32.2%. 2. The male patients are 3 times more than female patients. The highest frequency was recorded in the group 21-30 years of age. (34.1%). 3. Falls caused the greatest number of condylar fractures (45.2%) and next was in assult (25.6%), traffic accidents (22.4%). 4. Unilateral condylar fractures were present in 74.8%, giving a left: right ratio of 1.2:1. In cases of unilateral fracture, subcondylar fractures were by far the commonest (32.9%) but in cases of bilateral fracture, condylar neck fractures were by far the commonest. In children under 15 years of age, condylar neck fractures were more common but in patients over 16 years of age, subcondylar fractures were common. 5. Anteromedial fracture dislocations were by far the commonest (20.3%). In children under 15 years of age, fracture deviations were common but in patients over 16 years of age, fracture displacements were common. 6. 44.7% of patients with condylar fractures sustained the teeth injuries. Teeth fractures were by far the commonest. 7. Single condylar fractures showed a frequency of 30.5%. Of the concomitant fractures elsewhere in the mandible, symphysis fractures were by far the commonest (54.1%). 8. Associated other body injuries showed a frequency of 28.0%. Of them, head injuries were by far the commonest. 9. The mean interval from injury to treatment was 14.3 days. Of the treatment of condylar fractures, open reduction was by far the commonest (70.3%). Closed reduction comprised 19.9% and functional therapy comprised 8.5%. 10. In 67 patients with possible follow up period, the following complications were developed, two ankylosis, anterior open bite, mouth opening limitation, mouth opening deviation.

Patterns of facial fractures in children.

Morbidity and mortality among children is usually the result of trauma. Because a child's face is retruded relative to the protecting skull, has a thicker layer of adipose tissue, more elastic bones, flexible sutures lines, the presence of tooth buds within the jaws, and the lack of pneumatisation of the sinuses, the facial bones fracture less commonly than in adults. Our aim was to assess the patterns of such fractures in children who presented to the department of Oral and Maxillofacial Surgery, King Edward Medical University/Mayo Hospital Lahore, Pakistan. All 535 eligible children between the ages of 1-16 years who presented during the two years December 2009 - December 2011 were included in the study. Facial fractures were diagnosed by clinical examination, plain radiographs, and computed tomography, and the pattern of fractures of the facial bones including the frontal bone, orbital bones, maxilla, zygoma, naso-orbito-ethmoidal complex, mandible, and dentoalveolar region was documented. The male:female ratio was 2:1 with 369 male (70%) and 166 female (31%) patients. Fall was the cause in 212 (39%), and in 167 (31%) it was road traffic accidents, while sports were the cause in 135 (25%). The naso-orboto-ethmoid complex was fractured in 37 cases (7%) while 104 children (19%) presented with isolated fractures of the zygomatic bone. The maxilla was fractured in 195 cases (36%), the mandible in 380 (71%), and dentoalveolar trauma was the cause in 256 (50%). The mandible was the bone that was most often fractured (mostly in boys and usually as a result of falls during summer vacations), with the peak occurring in those aged 8-12 years.

Treatment of complex facial fractures:  clinical experience of different timing and order.

Given the variability of the timing and order of surgeries, it is difficult to choose the best treatment for patients with complex facial fractures. Based on the clinical experiences, the authors have reviewed their experience with the timing and order of operations depending on the sites of complex facial fractures and their concurrent injuries. The current study was based on a total of 105 patients with complex facial fractures from the year 2002 to 2011. After assessing the patients' clinical records, radiological data, and clinical photographs, the following data were analyzed: patients' age and sex, causes of injury, concurrent injuries, sites of fractures, the interval between trauma and the operations, the presence of additional surgeries, and the aesthetic and functional outcomes.For most of the patients, early operation was performed (within 2 weeks in 95.2%). Additional surgeries within 1 month after injuries were performed in 22 patients. Usually, a top-to-bottom direction repair was applied when head injuries were involved, and bottom-to-top direction repair was applied when occlusal problems were involved. Of 105 patients whom we were able to follow up, 49 patients showed complications or were dissatisfied with the outcomes. However, except them, most of the patients were satisfied with the outcomes of surgical treatments. There were 14 cases of cheek asymmetry, 9 enophthalmos, 30 paresthesia, 4 malocclusion, and a single case of persistent trismus.In the current study, satisfactory results could be achievable under the following principles: a repair should be done in the early stage after the onset of the injury; supportive surgeries should be done, if necessary, within 2 weeks (no later than 4 weeks); and the order of surgical treatment should be determined by the severity of bone fracture and the systemic status.

Prevalence of Ocular Complications in Patients with Zygomatic Bone Fractures in an Iranian Population.

Damages to the middle third of the facial bone generally involve the orbital skeleton and can lead to eye impairment. In this study, it is attempted to determine the incidence of ophthalmic injuries in maxillofacial trauma with zygomatic bone fractures. One hundred and fifteen cases with ophthalmic (ocular) involvement after maxillofacial trauma were referred to the Shariati Hospital, Tehran, Iran, and were visited at the Ophthalmology Department between 2016 and 2018. Zygomatic fractures and resulting ocular complications were evaluated in 87 males and 28 females with the mean ages of 26 and 32 years, respectively. Subconjunctival ecchymosis was detected in 23.07% of men and 21.05% of women. Displacement of the palpebral fissure was detected in 26.5% of men and 27.6% of women. Furthermore, the unequal pupillary level was observed in 18.37% of men and 15.78% of women. Diplopia was detected in 8.9% of men and 10.5% of women. Additionally, enophthalmos was observed in 23.1% of men and 25% of women. The most common ocular presentations in midfacial trauma are diplopia and reduced visual acuity. Even after the operation, a significant number of patients experience poor vision and diplopia. Ophthalmology consultation is essential for these patients.

Naso-Orbito-Ethmoid Fractures -- Complications

Mental health issues, as patients with facial injuries, are at greater risk of developing post-traumatic stress disorder or anxiety-related disorders, particularly those who were victims of assault. [31]

A study of sports-related orbital fractures in Singapore.

With an increased popularity of sport and active living worldwide, our study aims to explore the incidence and features of sports-related orbital fractures in Singapore. 1421 computer tomography (CT) imaging scans of the face and orbits done at the National University Hospital over a 24-month period from January 2013 and December 2014 were reviewed retrospectively for orbital fractures. We identified 483 orbital fractures of which sports injury was the fourth most common etiology (n = 65; 13.5%) after road traffic accident (n = 131; 27.1%), geriatric fall (n = 81; 16.8%) and workplace injury (n = 67; 13.9%). The three most common sport in orbital fractures were soccer (n = 20; 30.8%), bicycling (n = 11; 16.9%) and jogging (n = 8; 12.3%). The three most common fracture patterns were zygomatico-maxillary complex fractures (n = 24; 36.9%), isolated one wall blowout fractures (n = 19; 29.2%) and naso-orbito-ethmoid fractures (n = 7; 10.8%). Sports-related orbital fractures were associated with a low mean age of patients (45.9 years, range, 14-79 years), a higher proportion of males (n = 58; 89.2%) than that from geriatric falls (n = 37, 45.6%) (P < 0.01), a higher likelihood of unilaterality (n = 62; 95.4%) than that from traffic accidents (n = 99; 75.6%) (P < 0.01) and a lower likelihood of pan-facial involvement (n = 4; 6.15%) than that from traffic accident (n = 60; 45.8%) (P < 0.01). Sports-related orbital fractures are the fourth most common cause of orbital fractures. Though commonly seen in young male adults, in view of the aging population and people exercising more regularly, education of safety measures among sports users is paramount to preventing sports-related orbital fractures.

The causes and consequences of maxillofacial injuries in elderly people.

The occurrence of trauma in older people is well-documented; however the incidence of maxillofacial trauma is scarcely reported. Therefore, the objective of this study is to determine the causes and consequences of maxillofacial trauma in older people. A five-year (March 95 - March 2000) retrospective study was carried out of all patients over the age of 65 years with facial trauma presenting to Accident and Emergency Department (A&E). The information was collected using the medical notes and discharge summaries. The Departments of A&E and Maxillofacial Surgery. A total of 42 patients' records were examined for study related data. A total of 42 patients were seen during the study period. Thirty-six gave a history of a fall, of which 15 had tripped, 5 had slipped, 3 resulted from a Transient Ischaemic Attack (TIA), 1 as a result of alcohol abuse, in 1 a prosthetic knee gave way and 11 gave no cause for the fall. Of the remaining 6 patients, 5 were assaulted and 1 had a wardrobe fall on top of him. The majority of the falls occurred during the winter months. Maxillofacial injuries were noted in 27 of the 42 patients. Sixteen patients had cheekbone fractures, 8 mandibular fractures, 2 midface and 1 orbital complex fracture. Twenty-five percent of cheekbone fractures and 50% of mandibular fractures were treated surgically. Medical history was noted in 27 patients. This study clearly demonstrates the majority of the facial trauma in the older people can be treated conservatively unless the patients complain of functional problems.

Naso-Orbito-Ethmoid Fractures -- Differential Diagnosis

Pan-facial fractures - these are fractures involving the upper, middle, and lower regions of the face.

Basilar skull fracture

A basilar skull fracture is a break of a bone in the base of the skull. Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and may result in fluid leaking from the nose or ear. Meningitis occurs in about 14% of cases. Other complications include injuries to the cranial nerves or blood vessels. A basilar skull fracture typically requires a significant degree of trauma to occur. It is defined as a fracture of one or more of the temporal, occipital, sphenoid, frontal or ethmoid bone. Basilar skull fractures are divided into anterior fossa, middle fossa and posterior fossa fractures. Facial fractures often also occur. Diagnosis is typically by CT scan.

Zygomaticomaxillary complex fracture

There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity. Treatment Non-displaced or minimally displaced fractures may be treated conservatively. Open reduction and internal fixation is reserved for cases that are severely angulated or comminuted. The purpose of fixation is to restore the normal appearance of the face. Specific attention is given to the position of the malar eminence and reduction of orbital volume by realigning the zygoma and sphenoid. Failure to correct can result in rotational deformity and increase the volume of the orbit, causing the eye to sink inwards.

Do Radiologists and Surgeons Speak the Same Language? A Retrospective Review of Facial Trauma.

The objective of the present study is to examine the concordance of facial fracture classifications in patients with trauma who underwent surgery and to assess the epidemiologic findings associated with facial trauma. Patients with trauma who underwent facial CT examination and inpatient operative intervention during a 1-year period were retrospectively analyzed. Patient demographic characteristics, the mechanism of injury, the radiology report, the surgical diagnosis, and clinical indications were reviewed. Fractures were documented according to bone type and were classified into the following subtypes: LeFort 1, LeFort 2, LeFort 3, naso-orbital-ethmoidal, zygomaticomaxillary complex (ZMC), orbital, and mandibular. Concordance between the radiology and surgery reports was assessed. A total of 115,000 visits to the emergency department resulted in 9000 trauma activations and 3326 facial CT examinations. One hundred fifty-six patients (4.7%) underwent facial surgical intervention, and 133 cases met criteria for inclusion in the study. The mean injury severity score was 10.2 (range, 1-75). The three most frequently noted injury mechanisms were as follows: assault (77 cases [57.9%]), a traffic accident (21 cases [15.8%]), and a fall (20 cases [15%]). The three most frequently noted facial bone fractures were as follows: mandible (100 cases [75.2%]), maxilla (53 cases [39.8%]), and orbit (53 cases [39.8%]). The five descriptors most frequently found in the radiology and surgery reports were the mandibular angle (25 cases), the orbital floor (25 cases), the mandibular parasymphysis (22 cases), the mandibular body (21 cases), and ZMC fractures (19 cases). A classification was not specified in 31 of the radiologic impressions (22.5%), with 28 of 31 radiologists expecting the surgeon to read the full report. The descriptors used in the radiology and surgery reports matched in 73 cases (54.9%) and differed in 51 cases (38.3%). No classifications were used by one or both specialties in nine cases (6.8%). For 38.3% of patients needing facial surgery, descriptors used in the radiologic and surgery reports differed. Speaking a common language can potentially improve communication between the radiology and surgery services and can help expedite management of cases requiring surgery.

Epistaxis as the only initial symptom in pediatric naso-orbital-ethmoid fracture complicated with meningitis.

Epistaxis is a frequent finding in patients with facial trauma. Herein, we report an unusual presentation of pediatric naso-orbital-ethmoid (NOE) fracture with epistaxis as the only initial symptom. The course of the patient's condition was later complicated by meningitis, related in part to the delay in diagnosis. A 3-year-old girl with preexisting upper respiratory symptoms was involved in a traffic accident, sustaining blunt trauma to the right side of her face. During the initial examination, only right-sided epistaxis was noted. Five days later, she developed febrile convulsion and was admitted to the intensive care unit with other signs of meningitis such as mental status change and neck stiffness. Her craniofacial computed tomographic scan showed a right-sided NOE fracture with minimal displacement and without dura tear. The cerebrospinal fluid culture grew Streptococcus pneumoniae, which may be due to ascending infection as a result of cribriform plate fracture. Intravenous antibiotic therapy was initiated with good response, and she was discharged from the hospital after 2 weeks. The presence of epistaxis and periorbital bruise, together with other symptoms and signs, helps in the identification of NOE and cribriform plate fracture. A high index of suspicion with repetitive computed tomographic scans is necessary to achieve correct early diagnosis. Parental antibiotic therapy is indicated if ascending cerebrospinal fluid infection develops.

[Clinical studies on treatment of fractures of the zygomatic bone].

The author has made clinical studies on treatment of fractures of the zygomatic bone in terms of frequency of fractures according to sex, age, fracture type, main manifestations and treatment methods from 106 patients with zygomatic bone fractures among 969 patients with maxillofacial bone fractures. The results obtained were as follow: 1. The frequency of malar bone fracture was 4 times more in male than that in female. 2. The most prevalent age of malar bone fracture was 21-30 years of age, and the nexts were followed 11-20, 31-40, 0-10, 41-50, 51-60, 61-70, and over 71 in the orders. 3. Among maxillofacial bone fractures, mandibular fracture was most prevalent as 76.3%, and the nexts were followed by the maxilla (10.8%), the molar bone (9.7%) and the nasal bone (3.3%). 4. Among 106 fractures of the malar bone, zygomatic bone fracture only was occupied 48.1%, but the rests were accomplished by another maxillofacial bone fractures. 5. In classification of molar bone fractures according to Knight and North's, group 3 fractures were most prevalent, and followed by group 2, 1, 4 and 6 in the orders. 6. Main manifestations were upper cheek flattening, lower eyelid ptosis, subconjunctival ecchymosis, epistaxis, difficulty of mouth opening, pain during mouth opening and others in the orders. 7. 93.4% of malar bone fracture has been treated surgically, but the rests treated conservatively, and [symbol: see text] shaped elastic stapler wire has been effectively used to get fixation at zygomatico-maxillary fractures.

Dental trauma and bicycle safety: a report in Italian children and adolescents.

This retrospective study aims to analyze the pattern of oro-facial trauma from bicycle accidents in Italian children and adolescents, focusing on the safety devices used. The medical records of 1405 patients of the Dental Clinic of the University of Brescia, between the age of 0 to 18, who experienced a dento-facial trauma from the use of a bicycle, were analyzed. Data regarding age, gender, weight, height, dominant hand, type of bicycle, use of safety devices, location and type of dental trauma, teeth involved, bone fractures and soft tissue lesions were recorded. Statistical analysis was performed. The majority of the traumatic events occurred in children within the 8-10 years of age-range; 1085 teeth were injured, of which 975 permanent teeth (89.9%) and 110 primary teeth (10.1%). The most common dental lesions were the coronal fractures (complicated and not complicated) while the most frequently involved teeth were the upper central incisors; 11% of patients were also treated for maxillo-facial fractures. A protective helmet was worn only in 3% of the cases; not one patient wore a mouth-guard. The use of helmets was more frequent in children and adolescents riding racing-bikes competitively, compared to those who were mountain bikers (p < 0.05). Bicycle accidents can have serious oro-facial consequences. Therefore, national and regional efforts should be made in Italy to promote head and mouth protection in cycling.

The incidence and management of middle third facial fractures at the University College Hospital, Ibadan.

A study of 59 patients with middle third maxillofacial fractures over a 5 year period was undertaken. The incidence of, pattern of fracture, type of accompanying injuries, and assessment of the outcome of given treatment were studied. The young adult male featured prominently in the study giving a male/female ratio of 14:1. The zygomatico-maxillary complex was fractured in 42.4% of the cases, while the Le Fort 1 fracture was the most common of the Le Fort Fracture types. Road traffic accidents accounted for 81.4% of the aetiological factors, while armed robbery attacks was the next common source of trauma at 6.8%. Treatment by the Gillies temporal approach and immobilization within the tissues techniques produced very satisfactory results in 96% of the patients who received treatment. Loss of vision in one eye was the most common residual complication.

Le Fort fracture of skull

Signs and symptoms Le Fort I — Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin's sign is present characterised by ecchymosis in the region of greater palatine vessels. Le Fort II and Le Fort III (common) — Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound. Le Fort II — Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek.

[Facial bone fracture--statistical analysis and clinical aspects].

We experienced 102 cases of facial bone fracture during 16 months of 1986 to 1987. These cases were analyzed statistically concerning causes, age and locations of the fracture. These fractures have increased rapidly in number. The causes were classified into three types; occurrence during sport, traffic accident and fighting, which were equal in number. There were 85% males and 15% females in the patient cohort, which were concentrated at the ages of 10-20 years. A large part of the fractures was mostly consisted of maxillo-facial components (95%). These trends were similar to the previous report of our clinic (1972-1979). On the other hand, not only severe dysfunctioning cases but also complicated cases increased in number, so that the several clinical aspects were reported. Case 1: 17-year-old male presented with retraction of left cheek caused by Rugby foot ball, whose malar bone was dislocated backward and anticlockwise, was treated with oroantral reduction and with the intermaxillary packing of silicon blocks. Case 2: 10-year-old boy with complaint of double vision occurred by head blow to right eye. Pure type blowout fracture of the orbital floor was presented, which was reconstructed by silicon plate from the incision of the lower eyelid. Case 3: 59-year-old male presented with 6 month history of diplopia and retraction of left eye ball, had been under the conservative care by an eye doctor. X-ray examination showed the intraorbital soft tissue was blown out into the ethmoidal sinus. However the transethmoidal reduction was performed, the result was not satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

Craniofacial Trauma Due to Stone-pelting - Patterns of Injury and Management.

The aims of the study were to elucidate the pattern of stone-pelting induced cranio-facial injuries and to document soft and hard tissue injuries, their management, and complications. A retrospective descriptive study was conducted using a sample of patients reporting to our department in the years 2015 to 2020. Cranio-facial injuries were assessed for soft and hard tissue injuries, including tissue loss, and corresponding management. Follow up ranged from 18 ± 6 months. & A standardized surgical regime was followed for patient management, which included primary survey, debridement of wounds, and routine primary repair of soft tissue. Bony defect reconstruction was performed by open reduction and internal fixation. Cranial bone was used as split calvarial graft in postcraniectomy cranioplasty procedures, which were performed after 6 months. Local flaps were used for the reconstruction of soft tissue defects. Being a military hospital, majority of cases fell in the 20 to 30 age group with a male preponderance. The etiology in all cases was stone-pelting. Among cranio-facial injuries, cranial vault injuries and mid-face injuries (71%) were most prevalent, mandibular fractures (24%) and remaining were soft tissue injuries (5%). & Frontal & parietal bone injuries were seen in 23.6% cases (n = 9) and orbito-zygomatic complex injuries were seen in (36.8%) cases (n = 14). Isolated blow-out fractures were seen in 4 patients of our series. 52.6% of patients of our series suffered associated soft tissue injuries to the head, face, and neck region. The most common cause of injury was due to the direct impact of stone hitting the mid-face/cranial vault and the most common pattern of injury was gross comminution of the skeleton. & 2 patients suffered ocular injuries that required management and 6 patients of our series who suffered head injuries to the cranium required a secondary cranioplasty procedure (n = 4) &The most commonly used technique for treatment was open reduction internal fixation, which was used in 89% of patients. Soft-tissue injuries overall occurred most frequently on the forehead, nose, lips, and chin which was managed by primary suturing. Cranial vault injuries & orbito-zygomatic complex fractures are most commonly seen in patients with stone-pelting injuries. Early management of such injuries improves outcomes in terms of function and restitution of preinjury skeleton structure. The most common patterns seen is gross comminution to the cranio-facial skeleton that can be treated with immediate primary wound repair after meticulous wound debridement and open reduction and internal fixation. Importance of stone-pelting as a cause of craniofacial injuries is highlighted as it leads to significant disruption of craniofacial skeleton.

Maxillofacial fracture experiences: a review of 152 cases.

The fractures of facial structures lead to great morbidity. Cross-sectional studies are needed to evaluate the current state of maxillofacial traumas. Thus, this study aims to evaluate these experiences and to compare these results with the current literature. The medical records of the maxillofacial fracture cases hospitalized between January 2004 and November 2011 were examined. The age, sex, etiology, fracture localization and treatment method for each case were documented. The affected facial bones were grouped as mandible, maxilla, zygoma, naso-orbitoethmoid complex (NOEC) and blow-out. Nasal fractures were excluded. The cases were assigned to 3 groups with respect to age (below 16, above 65 and between 17 and 64). The chi Square test was used to assess the significance of the difference in mandibular fracture rates in the pediatric population compared to others. The total number of cases was 152. The total number of fractures was 185. Of the 152 cases, 117 were male and 35 were female. The average age was 31.4 (±18.3), ranging between 2 and 81. Thirty-one cases were 16 years old or less. Nine cases were 65 years old or more. Mandibular and zygomatic fractures were the most prevalent fractures in the adult group. Mandibular fractures were significantly more common in the pediatric age group compared to rest of the population (X(2), p<0.05). Traffic accidents were the most common etiological factor, with a 55.3% ratio. Open reduction and internal fixation was the most frequently conducted treatment modality in all age groups. Retrospective studies are important for the projection of future prospects. In summary, our results indicate that pediatric fractures are mostly in the lower face and usually affect the condylar region, which is consistent with the literature.

Zygomaticomaxillary complex fractures and their association with naso-orbito-ethmoid fractures:  a 5-year review.

Zygomaticomaxillary complex fractures associated with ipsilateral naso-orbito-ethmoidal fractures are more complex injuries than isolated zygomaticomaxillary complex fractures. This injury pattern can have significant long-term morbidity if not recognized and treated appropriately during the initial operation. The purpose of this study is to compare mechanisms of injury, treatment, and outcome between patients with zygomaticomaxillary complex fractures and those with zygomaticomaxillary complex and ipsilateral naso-orbito-ethmoidal fractures. A 5-year retrospective review of all patients treated with zygomaticomaxillary complex fractures at a level I trauma center was performed. Computed tomographic scans were reviewed to divide patients into those with zygomaticomaxillary complex fractures alone and those with zygomaticomaxillary complex and ipsilateral naso-orbito-ethmoidal fractures. Demographics, treatment protocols, outcomes, complications, reoperations, and length of follow-up were identified for both groups and compared to determine differences between these populations. A total of 245 patients were identified by the Current Procedural Terminology codes for zygomaticomaxillary complex fractures. One hundred eighty-five patients had zygomaticomaxillary complex fractures and 60 patients had zygomaticomaxillary complex/naso-orbito-ethmoidal injuries. The demographics for both populations were similar. There are differences between the groups with regard to mechanism of injury, operative findings, and techniques. The patients with zygomaticomaxillary complex/naso-orbito-ethmoidal fractures had higher rates of postoperative complications and deformities. Patients who sustain a zygomaticomaxillary complex fracture associated with an ipsilateral naso-orbito-ethmoidal fracture have a higher incidence of postoperative complications and deformities. It is important to recognize this fracture pattern early to help minimize postoperative morbidity. Risk, II.

An assessment of maxillofacial fractures: a 5-year study of 237 patients.

This descriptive analytical study assesses the cause, type, incidence, demographic, and treatment data of maxillofacial fractures managed at our medical center during a 5-year period and compares them with the existing body of literature on the subject. A 5-year retrospective clinical and epidemiologic study evaluated 237 patients treated for maxillofacial fractures from 1996 to 2001 at one medical center. There were 211 male patients (89%) and 26 (11%) female patients. The patients ranged in age from 3 to 73 years, with 59.0% (140 patients) in the 20- to 29-year age group. A number of parameters, including age, gender, cause of injury, site of injury, type of injury, treatment modalities, and complications, were evaluated. All maxillofacial injuries were assessed and treated by a single oral and maxillofacial surgeon. Other concomitant bodily injuries were treated by appropriate consultant specialists. There were 173 (72.9%) mandibular, 33 (13.9%) maxillary, 32 (13.5%) zygomatic, 57 (24.0%) zygomatico-orbital, 5 (2.1%) cranial, 5 (2.1%) nasal, and 4 (1.6%) frontal injuries. Car accidents caused 73 (30.8%), motorcycle accidents caused 55 (23.2%), altercations 23 (9.7%), sports 15 (6.3%), and warfare caused 23 (9.7%) of the maxillofacial injuries. Regarding distribution of mandibular fractures, 32% were seen in the condylar region, 29.3% in the symphyseal-parasymphyseal region, 20% in the angle region, 12.5% in the body, 3.1% in the ramus, 1.9% in the dentoalveolar, and 1.2% in the coronoid region. The distribution of maxillary fractures was Le Fort II in 18 (54.6%), Le Fort I in 8 (24.2%), Le Fort III in 4 (12.1%), and alveolar in 3 (9.1%). Of the 173 mandibular fractures, 56.9% were treated by closed reduction, 39.8% by open reduction, and 3.5% by observation only. Of 33 maxillary fractures, 54.6% were treated using closed reduction, 40.9% using open reduction, and 4.5% with observation only. Approximately 52.1% of the patients were treated under general anesthesia, and 47.9% were treated under local anesthesia and sedation. Postsurgical complications were recorded in 5% of patients. These complications included infection, asymmetry, and malocclusion. Overall mortality in this series was 0.84% (2 patients); mortality was caused by pulmonary infection. The findings of this study, compared with similar studies reported in the literature, support the view that the causes and incidence of maxillofacial injuries vary from 1 country to another.