Introduction
Materials and methods
Study design
Inclusion and exclusion criteria
Physical examination and radiological imaging
Treatment and outcome measures
Statistical analyses
Results
Patient characteristics
Treatment of midfacial fractures
Fracture type | Total (n) | Conservative treatment (n (%)) | Closed treatment (n (%)) | Surgical treatment (n (%)) |
---|---|---|---|---|
Midface fractures | 339 | 265 (78.2) | 32 (9.4) | 42 (12.4) |
Frontal sinus | 25 | 16 (64.0) | 0 (0.0) | 9 (36.0) |
Orbital rim and walls | 96 | 81 (84.4) | 4 (4.2) | 11 (11.5) |
Maxillary sinus | 30 | 26 (86.7) | 2 (6.7) | 2 (6.7) |
Zygomaticomaxillary complex | 134 | 107 (79.9) | 0 (0.0) | 27 (20.1) |
Nasoorbitoethmoid complex | 17 | 12 (70.6) | 1 (5.9) | 4 (23.5) |
Nasal bone | 126 | 89 (70.6) | 24 (19.0) | 13 (10.3) |
Le Fort I | 9 | 4 (44.4) | 1 (11.1) | 4 (44.4) |
Le Fort II | 8 | 2 (25.0) | 0 (0.0) | 6 (75.0) |
Le Fort III | 6 | 3 (50.0) | 0 (0.0) | 3 (50.0) |
Dentoalveolar complex | 15 | 6 (40.0) | 8 (53.3) | 1 (6.7) |
Mandible fractures | 66 | 29 (43.9) | 4 (6.1) | 33 (50.0) |
Symphyseal or parasymphyseal | 24 | 6 (25.0) | 0 (0.0) | 18 (75.0) |
Corpus | 17 | 5 (29.4) | 2 (11.8) | 10 (58.8) |
Angular | 8 | 0 (0.0) | 0 (0.0) | 8 (100.0) |
Ramus | 7 | 4 (57.1) | 0 (0.0) | 3 (42.9) |
Coronoid | 4 | 1 (25.0) | 0 (0.0) | 3 (75.0) |
Condylar process | 44 | 21 (47.7) | 4 (9.1) | 19 (43.2) |
Dentoalveolar complex | 1 | 0 (0.0) | 0 (0.0) | 1 (100.0) |
Findings related to midfacial fractures requiring treatment
Physical examination findings | Total observed | Midfacial fractures (n (%)) 1 | Midfacial fracture subtypes requiring active treatment (n (%)) 2 | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Fractures identified | Fractures requiring active treatment | Frontal sinus | Orbital rim and wall | Maxillary sinus | Zygomaticomaxillary complex | Nasoorbitoethmoid complex | Nasal bone | Le Fort I | Le Fort II | Le Fort III | Dentoalveolar complex | ||
Swelling | 621 | 294 (47.3) | 63 (10.1) | 9 (14.3) | 15 (23.8) | 3 (4.8) | 23 (36.5) | 5 (7.9) | 34 (54.0) | 4 (6.3) | 4 (6.3) | 3 (4.8) | 7 (11.1) |
Laceration | 430 | 200 (46.5) | 37 (8.6) | 5 (13.5) | 9 (24.3) | 2 (5.4) | 12 (32.4) | 5 (13.5) | 21 (56.8) | 3 (8.1) | 3 (8.1) | 2 (5.4) | 7 (18.9) |
Facial depression | 49 | 46 (93.9) | 23 (46.9) | 3 (13.0) | 3 (13.0) | 0 (0.0) | 18 (78.3) | 2 (8.7) | 6 (26.1) | 3 (13.0) | 3 (13.0) | 1 (4.3) | 1 (4.3) |
Peri-orbital hematoma | 355 | 199 (56.1) | 38 (10.7) | 7 (18.4) | 11 (28.9) | 3 (7.9) | 16 (42.1) | 5 (13.2) | 21 (55.3) | 3 (7.9) | 3 (7.9) | 3 (7.9) | 2 (5.3) |
Raccoon eyes | 55 | 35 (63.6) | 7 (12.7) | 2 (28.6) | 2 (28.6) | 2 (28.6) | 0 (0.0) | 0 (0.0) | 6 (85.7) | 1 (14.3) | 0 (0.0) | 2 (28.6) | 0 (0.0) |
Epistaxis | 285 | 194 (68.1) | 49 (17.2) | 5 (10.2) | 8 (16.3) | 4 (8.2) | 17 (34.7) | 5 (10.2) | 34 (69.4) | 4 (8.2) | 4 (8.2) | 2 (4.1) | 2 (4.1) |
Subconjunctival hemorrhage | 69 | 52 (75.4) | 10 (14.5) | 2 (20.0) | 3 (30.0) | 2 (20.0) | 4 (40.0) | 3 (30.0) | 6 (60.0) | 1 (10.0) | 1 (10.0) | 1 (10.0) | 1 (10.0) |
Ocular movement limitation | 13 | 12 (92.3) | 4 (30.8) | 1 (25.0) | 2 (50.0) | 1 (25.0) | 3 (75.0) | 1 (25.0) | 2 (50.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Diplopia | 20 | 13 (65.0) | 5 (25.0) | 1 (20.0) | 1 (20.0) | 0 (0.0) | 4 (80.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Infra-orbital nerve paresthesia | 62 | 50 (80.6) | 13 (21.0) | 0 (0.0) | 3 (23.1) | 0 (0.0) | 11 (84.6) | 1 (7.7) | 3 (23.1) | 1 (7.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Subjective malocclusion 3 | 47 | 27 (57.4) | 14 (29.8) | 1 (7.1) | 4 (28.6) | 0 (0.0) | 6 (42.9) | 0 (0.0) | 1 (7.1) | 2 (14.3) | 2 (14.3) | 0 (0.0) | 5 (35.7) |
Objective malocclusion 3 | 23 | 14 (60.9) | 9 (39.1) | 0 (0.0) | 1 (11.1) | 0 (0.0) | 2 (22.2) | 0 (0.0) | 1 (11.1) | 2 (22.2) | 2 (22.2) | 0 (0.0) | 5 (55.6) |
Tooth mobility or avulsion | 48 | 33 (68.8) | 17 (35.4) | 1 (5.9) | 2 (11.8) | 1 (5.9) | 1 (5.9) | 1 (5.9) | 6 (35.3) | 1 (5.9) | 4 (23.5) | 1 (5.9) | 9 (52.9) |
Palpable step-off | 68 | 62 (91.2) | 28 (41.2) | 5 (17.9) | 9 (32.1) | 2 (7.1) | 13 (46.4) | 3 (10.7) | 11 (39.3) | 3 (10.7) | 2 (7.1) | 2 (7.1) | 3 (10.7) |
Maxillary mobility | 36 | 20 (55.6) | 10 (27.8) | 2 (20.0) | 2 (20.0) | 0 (0.0) | 2 (20.0) | 1 (10.0) | 6 (60.0) | 4 (40.0) | 4 (40.0) | 1 (10.0) | 2 (20.0) |
Treatment of mandibular fractures
Findings related to mandibular fractures requiring treatment
Physical examination finding | Total observed | Mandibular fractures (n (%)) 1 | Mandibular fractures requiring active treatment (n (%)) 2 | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Fractures identified | Fractures requiring active treatment | Symphyseal or parasymphyseal | Corpus | Angular | Ramus | Coronoid | Condylar process | Dentoalveolar complex | ||
Swelling | 105 | 50 (47.6) | 25 (23.8) | 12 (48.0) | 7 (28.0) | 8 (32.0) | 2 (8.0) | 3 (12.0) | 14 (56.0) | 1 (4.0) |
Extra-oral laceration | 101 | 36 (35.6) | 19 (18.8) | 9 (47.4) | 6 (31.6) | 0 (0.0) | 1 (5.3) | 2 (10.5) | 16 (84.2) | 1 (5.3) |
Jaw movement pain | 129 | 59 (45.7) | 34 (26.4) | 18 (52.9) | 10 (29.4) | 7 (20.6) | 2 (5.9) | 1 (2.9) | 22 (64.7) | 0 (0.0) |
Mouth opening limitation | 88 | 54 (61.4) | 30 (34.1) | 16 (53.3) | 10 (33.3) | 5 (16.7) | 2 (6.7) | 1 (3.3) | 20 (66.7) | 0 (0.0) |
Inferior alveolar nerve paresthesia | 8 | 4 (50.0) | 3 (37.5) | 1 (33.3) | 1 (33.3) | 1 (33.3) | 0 (0.0) | 0 (0.0) | 2 (66.7) | 0 (0.0) |
Intra-oral hematoma | 35 | 19 (54.3) | 12 (34.3) | 6 (50.0) | 5 (41.7) | 2 (16.7) | 1 (8.3) | 1 (8.3) | 7 (58.3) | 1 (8.3) |
Intra-oral laceration | 62 | 24 (38.7) | 18 (29.0) | 8 (44.4) | 7 (38.9) | 5 (27.8) | 1 (5.6) | 1 (5.6) | 10 (55.6) | 1 (5.6) |
Palpable step-off | 17 | 16 (94.1) | 14 (82.4) | 6 (42.9) | 6 (42.9) | 4 (28.6) | 2 (14.3) | 3 (21.4) | 7 (50.0) | 1 (7.1) |
Tooth mobility or avulsion | 18 | 11 (61.1) | 8 (44.4) | 6 (75.0) | 1 (12.5) | 1 (12.5) | 0 (0.0) | 0 (0.0) | 6 (75.0) | 0 (0.0) |
Subjective malocclusion 3 | 69 | 37 (53.6) | 23 (33.3) | 15 (65.2) | 6 (26.1) | 3 (13.0) | 2 (8.7) | 1 (4.3) | 16 (69.6) | 0 (0.0) |
Objective malocclusion 3 | 42 | 28 (66.7) | 18 (42.9) | 10 (55.6) | 5 (27.8) | 3 (16.7) | 1 (5.6) | 1 (5.6) | 12 (66.7) | 0 (0.0) |
Angular compression test pain | 96 | 51 (53.1) | 33 (34.4) | 17 (51.5) | 10 (30.3) | 7 (21.2) | 2 (6.1) | 1 (3.0) | 21 (63.6) | 0 (0.0) |
Axial chin pressure pain | 82 | 50 (61.0) | 33 (40.2) | 17 (51.5) | 10 (30.3) | 7 (21.2) | 2 (6.1) | 1 (3.0) | 22 (66.7) | 0 (0.0) |
Tongue blade bite test | 22 | 15 (68.2) | 12 (54.5) | 7 (58.3) | 4 (33.3) | 2 (16.7) | 0 (0.0) | 0 (0.0) | 9 (75.0) | 0 (0.0) |
Diagnostic accuracy
Midface | Statistics | |||||
---|---|---|---|---|---|---|
Sens. (CI) | Spec. (CI) | PPV (CI) | NPV (CI) | LR+ (CI) | LR− (CI) | |
Swelling | 85.1 (75.3–91.5) | 19.4 (16.6–22.5) | 10.1 (8.0–12.8) | 92.4 (86.9–95.7) | 1.1 (1.0–1.2) | 0.8 (0.4–1.4) |
Laceration | 50.0 (38.9–61.1) | 43.2 (39.6–46.9) | 8.6 (6.3–11.6) | 89.0 (85.2–91.9) | 0.9 (0.7–1.1) | 1.2 (0.9–1.5) |
Facial depression | 33.3 (23.4–45.1) | 96.1 (94.4–97.4) | 46.9 (33.7–60.6) | 93.4 (91.3–95.0) | 8.6 (5.2–14.3) | 0.7 (0.6–0.8) |
Peri-orbital hematoma | 51.4 (40.2–62.4) | 54.2 (50.5–57.9) | 10.7 (7.9–14.4) | 91.2 (88.1–93.6) | 1.1 (0.9–1.4) | 0.9 (0.7–1.1) |
Raccoon eyes | 9.7 (4.8–18.7) | 93.1 (90.9–94.7) | 12.7 (6.3–24.0) | 90.8 (88.5–92.7) | 1.4 (0.7–3.0) | 1.0 (0.9–1.0) |
Epistaxis | 68.1 (56.6–77.7) | 65.4 (61.8–68.9) | 17.2 (13.3–22.0) | 95.1 (92.8–96.7) | 2.0 (1.6–2.4) | 0.5 (0.3–0.7) |
Subconjunctival hemorrhage | 15.2 (8.4–25.7) | 91.0 (88.6–93.0) | 14.5 (8.1–24.7) | 91.5 (89.1–93.4) | 1.7 (0.9–3.1) | 0.9 (0.8–1.0) |
Ocular movement limitation | 6.3 (2.5–15.0) | 98.6 (97.3–99.3) | 30.8 (12.7–57.6) | 91.3 (88.9–93.1) | 4.4 (1.4–13.9) | 1.0 (0.9–1.0) |
Diplopia | 8.1 (3.5–17.5) | 97.6 (96.1–98.6) | 25.0 (11.2–46.9) | 91.6 (89.2–93.4) | 3.4 (1.3–9.1) | 0.9 (0.9–1.0) |
Infra-orbital nerve paresthesia | 20.0 (12.1–31.3) | 92.2 (89.9–94.1) | 21.0 (12.7–32.6) | 91.8 (89.4–93.7) | 2.6 (1.5–4.5) | 0.9 (0.8–1.0) |
Subjective malocclusion 1 | 12.5 (5.0–28.1) | 97.2 (94.8–98.5) | 30.8 (12.7–57.6) | 91.8 (88.4–94.3) | 4.5 (1.5–13.8) | 0.9 (0.8–1.0) |
Objective malocclusion 1 | 0.0 (0.0–11.0) | 98.5 (96.5–99.3) | 0.0 (0.0–43.4) | 91.2 (87.8–93.7) | 1/∞ | 1.0 (1.0–1.0) |
Tooth mobility or avulsion | 23.0 (14.9–33.7) | 95.4 (93.6–96.8) | 35.4 (23.4–49.6) | 91.9 (89.7–93.7) | 5.0 (2.9–8.7) | 0.8 (0.7–0.9) |
Palpable step-off | 38.9 (28.5–50.4) | 93.9 (91.8–95.5) | 41.2 (30.3–53.0) | 93.4 (91.2–95.0) | 6.4 (4.2–9.7) | 0.7 (0.5–0.8) |
Maxillary mobility | 15.4 (8.6–26.1) | 96.0 (94.2–97.3) | 27.8 (15.8–44.0) | 91.9 (89.6–93.7) | 3.9 (1.9–7.6) | 0.9 (0.8–1.0) |
Mandible | ||||||
Swelling | 67.6 (51.5–80.4) | 67.1 (60.9–72.7) | 23.8 (16.7–32.8) | 93.1 (88.4–96.0) | 2.1 (1.5–2.7) | 0.5 (0.3–0.8) |
Extra-oral laceration | 51.4 (35.9–66.6) | 66.3 (60.1–71.9) | 18.8 (12.4–27.5) | 89.9 (84.7–93.5) | 1.5 (1.1–2.2) | 0.7 (0.5–1.0) |
Jaw movement pain | 100.0 (89.8–100.0) | 59.9 (53.6–65.9) | 26.4 (19.5–34.6) | 100.0 (97.4–100.0) | 2.5 (2.1–2.9) | 1/∞ |
Mouth opening limitation | 88.2 (73.4–95.3) | 75.7 (69.9–80.7) | 34.1 (25.0–44.5) | 97.8 (94.6–99.2) | 3.6 (2.8–4.7) | 0.2 (0.1–0.4) |
Inferior alveolar nerve paresthesia | 9.1 (3.1–23.6) | 97.8 (95.0–99.1) | 37.5 (13.7–69.4) | 88.1 (83.6–91.6) | 4.1 (1.0–16.5) | 0.9 (0.8–1.0) |
Intra-oral hematoma | 40.0 (24.6–57.7) | 90.2 (85.7–93.4) | 34.3 (20.8–50.8) | 92.1 (87.9–95.0) | 4.1 (2.3–7.3) | 0.7 (0.5–0.9) |
Intra-oral laceration | 56.3 (39.3–71.8) | 81.4 (75.9–85.8) | 29.0 (19.2–41.3) | 93.2 (88.9–95.9) | 3.0 (2.0–4.5) | 0.5 (0.4–0.8) |
Palpable step-off | 42.4 (27.2–59.2) | 98.7 (96.3–99.6) | 82.4 (59.0–93.8) | 92.5 (88.5–95.1) | 33.4 (10.1–110.0) | 0.6 (0.4–0.8) |
Tooth mobility or avulsion | 22.2 (11.7–38.1) | 95.8 (92.4–97.7) | 44.4 (24.6–66.3) | 89.1 (84.6–92.3) | 5.3 (2.2–12.5) | 0.8 (0.7–1.0) |
Subjective malocclusion 1 | 89.5 (68.6–97.1) | 64.1 (48.4–77.3) | 54.8 (37.8–70.8) | 92.6 (76.6–97.9) | 2.5 (1.6–3.9) | 0.2 (0.0–0.6) |
Objective malocclusion 1 | 68.4 (46.0–84.6) | 77.5 (62.5–87.7) | 59.1 (38.7–76.7) | 83.8 (68.9–92.3) | 3.0 (1.6–5.8) | 0.4 (0.2–0.8) |
Angular compression test pain | 97.1 (85.1–99.5) | 73.0 (66.9–78.3) | 34.4 (25.6–44.3) | 99.4 (96.8–99.9) | 3.6 (2.9–4.5) | 0.0 (0.0–0.3) |
Axial chin pressure pain | 97.1 (85.1–99.5) | 78.3 (72.5–83.2) | 40.2 (30.3–51.1) | 99.4 (96.9–99.9) | 4.5 (3.5–5.8) | 0.0 (0.0–0.3) |
Tongue blade bite test | 75.0 (50.5–89.8) | 93.5 (88.5–96.4) | 54.5 (34.7–73.1) | 97.3 (93.3–98.9) | 11.6 (6.0–22.4) | 0.3 (0.1–0.6) |
Clinical decision aids
Clinical decision aid | Physical examination findings | Definitions | Contingency table outcomes | Cumulative diagnostic accuracy | ||||||
---|---|---|---|---|---|---|---|---|---|---|
TN (%) | FN (%) | Sens. (CI) | Spec. (CI) | PPV (CI) | NPV (CI) | LR+ (CI) | LR− (CI) | |||
Midfacial trauma | Facial depression | Unilateral flattening of the malar eminence or zygomaticomaxillary complex | 647 (84.5) | 46 (6.0) | 37.8 (27.6–49.2) | 93.5 (91.4–95.1) | 38.4 (28.1–49.8) | 93.4 (91.3–95.0) | 5.8 (3.9–8.7) | 0.7 (0.6–0.8) |
Epistaxis | A unilateral or bilateral active or past nosebleed | 434 (56.7) | 14 (1.8) | 81.1 (70.7–88.4) | 62.7 (59.1–66.2) | 18.9 (14.9–23.5) | 96.9 (94.8–98.1) | 2.2 (1.9–2.5) | 0.3 (0.2–0.5) | |
Ocular movement limitation | Unilateral restricted gazing or limitation of the eye movements in any direction | 405 (52.9) | 12 (1.6) | 83.8 (73.8–90.5) | 58.5 (54.8–62.1) | 17.8 (14.1–22.1) | 97.1 (95.0–98.3) | 2.0 (1.8–2.3) | 0.3 (0.2–0.5) | |
Palpable step-off | The presence of a bony step-off found during palpation of the zygomatic arch, infra-orbital rim, supra and lateral orbital rim, nasal bridge and zygomaticoalveolar crest intra-orally | 378 (49.3) | 8 (1.0) | 89.2 (80.1–94.4) | 54.6 (50.9–58.3) | 17.4 (13.9–21.5) | 97.9 (96.0–98.9) | 2.0 (1.8–2.2) | 0.2 (0.1–0.4) | |
Objective malocclusion | Objectively identified traumatic misalignment of the maxillary and mandibular dental arches | 278 (36.3) | 5 (0.7) | 93.2 (85.1–97.1) | 40.2 (36.6–43.9) | 14.3 (11.4–17.7) | 98.2 (95.9–99.2) | 1.6 (1.4–1.7) | 0.2 (0.1–0.4) | |
Tooth mobility or avulsion | Mobility or avulsion of any maxillary tooth element | 267 (34.9) | 2 (0.3) | 97.3 (90.7–99.3) | 38.6 (35.0–42.3) | 14.5 (11.7–17.9) | 99.3 (97.3–99.8) | 1.6 (1.5–1.7) | 0.1 (0.0–0.3) | |
Mandible trauma | Mouth opening limitation | The reported inability to fully open the mouth or a measured mouth opening of less than 35 mm | 181 (64.6) | 4 (1.4) | 89.2 (75.3–95.7) | 74.5 (68.7–79.6) | 34.7 (25.9–44.7) | 97.8 (94.6–99.2) | 3.5 (2.7–4.5) | 0.1 (0.1–0.4) |
Jaw movement pain | Evident presence of pain during opening, protrusion or lateral movement of the mandible | 137 (48.9) | 0 (0.0) | 100.0 (90.6–100.0) | 56.4 (50.1–62.5) | 25.9 (19.4–33.6) | 100.0 (97.3–100.0) | 2.3 (2.0–2.6) | 1/∞ | |
Objective malocclusion | Objectively identified traumatic misalignment of the maxillary and mandibular dental arches | 101 (36.1) | 0 (0.0) | 100.0 (90.6–100.0) | 41.6 (35.5–47.8) | 20.7 (15.4–27.2) | 100.0 (96.3–100.0) | 1.7 (1.5–1.9) | 1/∞ | |
Tooth mobility or avulsion | Mobility or avulsion of any mandibular tooth element | 95 (33.9) | 0 (0.0) | 100.0 (90.6–100.0) | 39.1 (33.2–45.4) | 20.0 (14.9–26.3) | 100.0 (96.1–100.0) | 1.6 (1.5–1.8) | 1/∞ |