A Retrospective Study of the Presentation, Imaging Findings, and Outcomes in 195 Patients with Maxillofacial Fractures Treated with Closed Reduction or Open Reduction with Internal Fixation

Introduction

Maxillofacial fractures compromise both function and aesthetics, and are associated with considerable morbidity [1–3]. Their severity is determined by the site, force, and direction of impact [4]. The most common causes are traffic accidents, falls, and assaults, with incidence patterns influenced by socioeconomic and geographic factors [5–7].

Şanlıurfa, a city in southeastern Turkey, has one of the lowest physician-to-population ratios in the country [8], limiting timely access to trauma care. Such disparities highlight the need for regional studies that describe trauma characteristics and guide preventive strategies [9,10].

Recent studies from developing countries have highlighted how socioeconomic conditions, including poor road infrastructure and limited public adherence to safety measures, contribute significantly to the incidence and pattern of maxillofacial trauma [9]. Our study adds to this body of evidence by providing data from Şanlıurfa, Turkey, a region similarly characterized by limited healthcare access and low physician density, underscoring the impact of regional disparities on trauma outcomes.

Therefore, this retrospective study aimed to evaluate the presentation, imaging findings, and outcomes in 195 patients with maxillofacial fractures treated with closed reduction or open reduction with internal fixation (ORIF) at Harran University Faculty of Dentistry Hospital.

Material and Methods

ETHICAL CONSIDERATIONS:

This retrospective study was conducted in accordance with the Declaration of Helsinki and approved by the Harran University Clinical Research Ethics Committee (approval date and number: 11.12.2023; HRÜ/23.23.47). Written informed consent was obtained from all patients.

STUDY POPULATION:

A total of 195 patients with hard tissue maxillofacial fractures treated between January 2021 and December 2024 were included. Eligible fractures included mandibular (symphysis, parasymphysis, corpus, angulus, condyle, alveolus), maxillary, nasal, and zygomatic fractures. Exclusion criteria were isolated soft tissue injuries and incomplete records.

SURGICAL MANAGEMENT:

Mandibular fractures were primarily treated with ORIF using titanium miniplates and screws. Intermaxillary fixation (IMF) with screws and elastics was used in selected non-complex cases. Dental splints were applied in pediatric or minimally displaced fractures. Midfacial fractures (maxilla, nasal, or zygomatic) were predominantly managed with closed reduction techniques. All surgeries were performed under general anesthesia with nasotracheal intubation.

DATA COLLECTION:

Demographic and clinical data, including age, sex, etiology, fracture site, and treatment, were collected from electronic medical records. Variables were categorized by age groups, cause of injury, fracture site, and treatment modality.

A total of 195 patients with maxillofacial fractures treated at Harran University Faculty of Dentistry Hospital between January 2021 and December 2024 were included in this study. The inclusion criteria were: (1) patients with complete clinical and surgical records, selected to ensure data completeness and reliability for accurate analysis. Exclusion criteria included: (1) patients presenting only with soft tissue injuries and (2) patients who underwent surgical treatment but had incomplete records, as these cases were excluded to maintain the study’s focus on hard tissue fractures and to allow precise classification and outcome evaluation. A post-hoc power analysis was conducted using the total sample size (n=195) to retrospectively assess whether the study had sufficient statistical power to detect medium effect size differences (Cohen’s d=0.5) between treatment groups (eg, open reduction vs IMF) and demographic variables such as sex. Although no specific a priori hypothesis testing was planned, this analysis indicated an approximate power of 93.5% at a significance level of 0.05, suggesting that the sample size was adequate for exploratory between-group comparisons.

All surgical procedures were performed under general anesthesia with nasotracheal intubation. ORIF procedures were carried out using titanium miniplates and screws. In all patients in whom IMF was applied, IMF screws and elastics were used. Both approaches were carried out in accordance with previously established methods described in the literature [11].

Patient data were collected from the hospital’s electronic medical record system. The following variables were analyzed: patient name, medical record number, sex, age, cause of injury, fracture location(s), and treatment method(s). Data were categorized as follows:

Age groups: 0–10 years, 11–20 years, 21–30 years, 31–40 years, and 41 years and older;

Causes of injury: traffic accidents, falls from height, and assaults;

Fracture sites: symphysis, parasymphysis, corpus, angulus, condyle, alveolus, maxilla, nasal, and zygomatic;

Treatment methods: IMF, ORIF, and dental splint.

STATISTICAL ANALYSIS:

For statistical analysis, frequency distribution was first used to evaluate the demographic characteristics of the patients. To analyze relationships between variables such as cause of injury and sex, the expected values for each observation were considered. If any expected frequency in a contingency table was less than 5, Fisher’s exact test was used. Otherwise, the chi-square test of independence was applied.

Categorical data were presented as frequencies (n) and percentages (%). A P-value of less than 0.05 was considered statistically significant. All analyses were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Patients with incomplete clinical or surgical data were excluded at the initial stage, and as a result, the final dataset contained no missing data for the analyzed variables. Therefore, no additional methods for handling missing data or sensitivity analyses were required.

Results

ANALYSIS BY CAUSE:

Table 2 presents the relationships between the fracture cause groups and the demographic characteristics of the individuals included in the study. Upon examination of the findings, a statistically significant relationship was found between age and the cause of the fracture (P<0.05). It was observed that the majority of fractures in the 4–10 years age group resulted from falls. In individuals aged 11–30 years, fractures were more commonly caused by accidents. A significant relationship was also found between sex and the cause of the fracture (P<0.05). The rate of fractures due to assault and accidents was higher in male patients than in female patients, while the rate of fractures due to falls was higher in female patients than in male patients.

When treatment methods were examined, a significant relationship was found between the cause of fracture and the use of open reduction and splint techniques (P<0.05). Open reduction was more frequently applied in individuals who sustained injuries due to assault or traffic accidents. The splint method was most commonly preferred in cases resulting from falls and accidents.

When evaluating fracture sites, a statistically significant relationship was found between the cause of fracture and fractures in the angulus, condyle, alveolus, maxilla, nasal, and zygomatic regions (P<0.05). Fractures in the angulus, maxilla, nasal, and zygomatic areas mostly occurred due to accidents, while alveolar fractures mainly resulted from falls and accidents. On the other hand, no statistically significant relationship was found between the cause of fracture and fractures in the symphysis, parasymphysis, and corpus regions (P>0.05).

ANALYSIS BY SEX:

Table 3 presents the relationships between sex and the other demographic characteristics of the individuals included in the study. Upon examination of the findings, no statistically significant relationship was found between age and sex (P>0.05); the age distributions of male and female individuals were similar. A statistically significant relationship was, however, found between the cause of fracture and sex (P<0.05). The rate of fractures due to assault was significantly higher in male individuals than in female individuals. It was also observed that fractures due to falls were more common in female individuals. Regarding treatment methods, a statistically significant relationship was found only between the open reduction method and sex (P<0.05); the open reduction method was more frequently applied in male patients than in female patients. No significant difference was observed between sex groups in terms of the IMF and splint methods (P>0.05). Additionally, no significant relationship was found between sex and any fracture site (P>0.05), indicating that the distribution of fracture sites was similar in male and female individuals. Overall, these demographic and clinical patterns highlight the disproportionately high risk of mandibular fractures among young male patients, particularly due to traffic accidents, underscoring the importance of identifying at-risk groups to guide preventive measures and treatment strategies. These statistical associations align with the study’s aim of identifying key epidemiological patterns and clinical characteristics of maxillofacial fractures, particularly in highlighting high-risk groups and guiding management strategies.

Discussion

Maxillofacial traumas frequently affect both the soft and hard tissues of the facial region and may result in various clinical complications requiring multidisciplinary management [12,13]. Given the anatomical and functional significance of the maxillofacial region, a thorough understanding of the epidemiological patterns and clinical characteristics of such injuries is essential for optimizing both preventive strategies and therapeutic approaches [14].

In the present study, a marked male predominance was observed, with 67.69% of the cases involving male patients. Although the age distribution did not show a statistically significant difference between sexes, the predominance of male patients is consistent with findings from other studies, particularly in developing countries. This is likely attributable to the increased exposure of men to high-risk activities such as vehicular driving, physical labor, and contact sports [15,16]. However, reports from more developed regions have demonstrated a relative increase in the incidence of facial trauma among female patients, potentially reflecting evolving social dynamics and greater participation of women in occupational and recreational activities.

The etiology of maxillofacial fractures is known to vary geographically and temporally [17–19]. In the present series, traffic accidents were the most common causes of injury, followed by assaults and falls. This finding reflects regional socioeconomic conditions, including inadequate enforcement of traffic regulations, poor road infrastructure, limited use of safety devices, and lower public awareness regarding accident prevention [20–22]. In contrast, studies from high-income countries often identify alcohol-related interpersonal violence as the predominant cause of facial trauma [23].

A significant association was found between sex and cause of injury. Male patients were more frequently involved in traffic accidents and assault-related trauma, whereas falls were more commonly observed among female patients. This distribution may be influenced by sex-related behavioral patterns and risk exposure.

Anatomically, the mandible was the most frequently affected facial bone in our cohort, particularly the parasymphysis (29.23%), symphysis (24.62%), corpus (20.51%), angulus (15.90%), and condyle (17.44%) regions. These findings align with previous reports from Asia, where mandibular fractures are more prevalent, in contrast with studies from Western countries that report higher incidences of nasal bone and zygomatic complex fractures [16,23]. It is noteworthy that the current study was conducted in a dental hospital, which may lead to an overrepresentation of mandibular fractures, as patients with midfacial injuries may present more frequently to otolaryngology clinics. Nonetheless, fractures were also observed in the maxilla (16.92%), alveolar region (10.26%), nasal bones (10.26%), and zygomatic complex (9.23%).

In a study conducted in northeastern Iran, Samieirad et al [24] similarly reported that mandibular fractures were the most common type of maxillofacial trauma (58.8%), with the mandibular body (39.67%) and parasymphysis (20.19%) being the most frequently affected regions. Moreover, in their study, motor vehicle accidents, particularly motorcycle crashes (62.7%), were the predominant cause of fractures. These results closely mirror our findings, where traffic accidents accounted for 63.08% of injuries and mandibular fractures were the most prevalent type. Additionally, the male predominance observed in our study (67.69%) is comparable to that reported by Samieirad et al (80.3%) [24]. These similarities highlight the significant influence of regional and socioeconomic factors on the epidemiology of maxillofacial fractures and underscore common patterns in developing countries where traffic safety compliance is often suboptimal.

The highest incidence of fractures was observed in individuals aged 21–30 years, consistent with the literature [25–29]. This age group is generally characterized by increased outdoor activity, occupational engagement, and participation in high-risk behavior, thereby increasing susceptibility to trauma.

From a therapeutic perspective, ORIF was the most commonly employed treatment modality, particularly in traffic accident-related trauma. This is likely due to the higher impact forces and resultant comminuted fractures that necessitate surgical intervention. Conversely, splint therapy was more frequently used in fall-related injuries, which were predominantly seen in pediatric patients. Given the ongoing development of the jaws and the presence of tooth germs, conservative treatment modalities are often preferred in children to minimize the risk of iatrogenic damage.

Recent advances in maxillofacial trauma management have introduced innovative solutions for challenging fracture cases. For instance, Kawai et al [30] reported the use of a custom-made titanium mesh combined with a miniplate for the fixation of a high condylar neck fracture, enabling precise repositioning and stable fixation of displaced fragments. This approach, supported by 3D virtual planning and preoperative modeling, highlights the potential of personalized implants and digital technologies to overcome anatomical and biomechanical challenges in complex mandibular fractures. Although our study primarily focuses on conventional ORIF techniques applied across a broad patient cohort, these emerging methods underscore the evolving landscape of maxillofacial surgery and point toward promising directions for future research and clinical practice, particularly in cases where standard fixation methods may be insufficient.

The widespread use and effectiveness of ORIF have been emphasized in various studies. In a study conducted in Iran, 61.9% of 502 patients were treated surgically with ORIF, particularly favoring individuals aged 16–59 years [31]. Similarly, in a study from India, 71.9% of 491 fracture cases were managed with ORIF, confirming its status as a preferred treatment modality in mandibular fractures [32]. When compared with IMF, ORIF has been shown to provide superior outcomes, especially in comminuted mandibular fractures, by facilitating early primary repair and stable internal fixation [33]. Furthermore, the postoperative surgical site infection rate after ORIF has been reported as 4.2%, suggesting that this technique maintains an acceptable level of surgical risk [34]. These findings collectively reinforce the role of ORIF as the gold standard approach for the management of complex mandibular fractures, particularly in young and middle-aged adult patients.

This study has some limitations. First, its nature as a retrospective and single-center study may limit the generalizability of the findings. Second, potential biases resulting from incomplete patient records may affect the accuracy of the reported epidemiological data. In addition, the fact that the study was conducted in a single-center, maxillofacial surgery clinic may have led to the exclusion of fractures treated in different clinics and to an underestimation of the incidence of midface fractures [35]. In addition, the fact that the traumas included only hard tissue traumas may have led to bias in the evaluation of etiological, epidemiological, and treatment options [36,37]. Additionally, no multivariable analyses were conducted to adjust for potential confounding variables, which may have influenced the observed associations. Future prospective, multicenter studies that include comprehensive injury details and long-term follow-up data may provide more reliable and generalizable results.

Conclusions

This study demonstrates that maxillofacial fractures predominantly affect young to middle-aged male patients, with traffic accidents and falls identified as the leading causes. The mandible – particularly the parasymphysis and symphysis regions – was the most frequently fractured bone, and ORIF was the primary treatment method.

The findings also reflect the influence of regional healthcare disparities in Şanlıurfa, where limited physician availability and restricted access to specialized trauma care may delay early intervention and contribute to higher reliance on surgical management. The predominance of severe, accident-related mandibular fractures requiring ORIF highlights the burden placed on under-resourced centers. These results underscore the need for improved road safety enforcement, increased trauma care capacity, and targeted preventive strategies in regions with limited healthcare infrastructure.

Future research should investigate long-term functional and aesthetic outcomes of different treatment modalities and explore the role of emerging digital technologies in optimizing patient care in resource-constrained settings.