Impact of Delayed Surgery on Outcomes of Panfacial Fractures in Low-Resource Healthcare Settings: A Retrospective Cohort Study

Impact of Delayed Surgery on Outcomes of Panfacial Fractures in Low-Resource Healthcare Settings: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Delayed Surgery on Outcomes of Panfacial Fractures in Low-Resource Healthcare Settings: A Retrospective Cohort Study Chandrashekhar Chattopadhyay, Vikas Deo, Charu Chouhan, Mamta Patel, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7545726/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Panfacial fractures, involving simultaneous injuries to the upper, mid, and lower facial skeleton, pose significant challenges due to their complexity. Timely surgical intervention is critical for optimal functional and aesthetic outcomes, yet delays are common in resource-limited settings. Objective: To assess the impact of delayed surgical treatment on outcomes in patients with panfacial fractures. Methods: This retrospective cohort study reviewed 120 adults (aged 18–65 years) treated for panfacial fractures at a tertiary centre in Western India from January 2022 to June 2025. Fractures included combinations of frontal, Naso-orbito-ethmoidal, zygomatic, and mandibular injuries. Patients were grouped by surgical timing: early (≤7 days post-injury) or delayed (>7 to ≤30 days). Cases beyond 30 days were excluded to avoid secondary deformities. Outcomes evaluated included function (Oral Health Impact Profile, Functional Disability Index), aesthetics (Facial Aesthetic Index, patient satisfaction), and complications (e.g., asymmetry, chronic pain). Statistical analyses used t-tests, chi-square tests, logistic regression, and Kaplan–Meier survival analysis. Results: Among 120 patients (88% male, mean age 32 ± 10 years), 54 (45%) underwent early surgery and 66 (55%) delayed surgery, primarily due to road traffic accidents (82%). Delayed surgery was associated with worse functional outcomes (OHIP-14: 18.7 vs. 12.5; FDI: 20.1 vs. 15.3; both p<0.001), reduced aesthetic scores (FAI: 75 vs. 85; p<0.01), and higher rates of complications, including asymmetry (25% vs. 12%) and chronic pain (28% vs. 15%). Delayed surgery independently predicted adverse outcomes (OR 2.3, 95% CI 1.5–3.6). Conclusion: Surgical delays beyond 7 days significantly impair outcomes in panfacial fractures. Enhanced trauma care systems are vital to ensure timely surgery in low-resource settings. Dentistry Panfacial fractures delayed surgery functional outcomes aesthetic outcomes trauma care resource-limited settings Figures Figure 1 Figure 2 Figure 3 Introduction Panfacial fractures, defined as simultaneous involvement of at least two of the upper, mid, and lower thirds of the facial skeleton, remain among the most complex challenges in maxillofacial surgery. These injuries, usually caused by high-energy trauma such as road traffic accidents (RTAs), assaults, or falls, compromise mastication, speech, and aesthetics, often requiring immediate intervention to restore anatomical alignment and function [ 1 , 2 ]. Open reduction and internal fixation (ORIF) within the first week is widely regarded as the standard of care, providing optimal restoration of symmetry, occlusion, and psychosocial recovery [ 3 – 5 ]. However, in resource-limited settings such as many regions of India, delays are common due to limited imaging facilities, shortages of specialized surgical teams, and referral delays [ 6 , 7 ]. Such delays may worsen outcomes through infection, malunion, scarring, and long-term psychological distress [ 8 , 9 ]. Although early intervention is emphasized in global literature, few studies from low- and middle-income countries have quantified the impact of delayed surgery in panfacial fractures [ 10 , 11 ]. This study aims to assess functional, aesthetic, and psychological outcomes in patients undergoing early versus delayed surgical repair at a tertiary care centre in India. Materials and Methods This retrospective cohort study reviewed 120 adults (aged 18–65 years) treated for panfacial fractures at a tertiary centre in Western India from January 2022 to June 2025. Panfacial fractures were defined as injuries involving at least two of the upper (frontal), mid (naso-orbito-ethmoidal, zygomatic), and lower (mandibular) facial regions, confirmed by computed tomography (CT). Patients were grouped by surgical timing: early (≤ 7 days post-injury) or delayed (> 7 to ≤ 30 days). Cases beyond 30 days were excluded to avoid secondary deformities requiring different management [ 12 , 13 ]. Data were extracted from medical records, including demographics, injury mechanism (e.g., RTAs, assaults), fracture patterns, and surgical details. Outcomes included functional measures (Oral Health Impact Profile [OHIP-14], Functional Disability Index [FDI]), aesthetic outcomes (Facial Aesthetic Index [FAI], patient satisfaction via Likert scale), and complications (e.g., infection, asymmetry, chronic pain). Follow-up was conducted at 1-, 6-, and 12-months post-surgery [ 14 – 16 ]. Statistical analyses included t-tests for continuous outcomes (e.g., OHIP-14, FDI, FAI scores), chi-square tests for categorical outcomes (e.g., complication rates), logistic regression to identify predictors of poor outcomes, and Kaplan–Meier survival analysis for complication-free survival. A p-value < 0.05 was considered significant. Data were analysed using SPSS version 26 [ 17 – 19 ]. Results Of 120 patients (88% male, mean age 32 ± 10 years), 54 (45%) underwent early surgery (≤ 7 days) and 66 (55%) delayed surgery (> 7 to ≤ 30 days). RTAs were the primary cause (82%), followed by assaults (12%) and falls (6%). Fracture patterns included combinations of frontal (38%), naso-orbito-ethmoidal (45%), zygomatic (62%), and mandibular (78%) injuries [ 14 – 16 ]. TABLE 1 At 12 months, delayed surgery was associated with significantly worse functional outcomes (OHIP-14: 18.7 vs. 12.5; FDI: 20.1 vs. 15.3; both p < 0.001), lower aesthetic scores (FAI: 75 vs. 85; p < 0.01), and higher complication rates, including asymmetry (25% vs. 12%), chronic pain (28% vs. 15%), and infection (10% vs. 5%) [ 17 – 19 ]. TABLE 2& TABLE 3, Fig. 2 Logistic regression identified delayed surgery (OR 2.3, 95% CI 1.5–3.6), socioeconomic disadvantage, and poor hygiene as independent predictors of adverse outcomes TABLE 4 & Fig. 3 . Kaplan–Meier analysis showed higher complication-free survival in the early surgery group (p < 0.01) [ 19 ]. Figure 1 Discussion This retrospective cohort study underscores the detrimental impact of surgical delays beyond 7 days, but within 30 days, on outcomes in panfacial fractures, with patients in the delayed surgery group experiencing significantly worse functional recovery, aesthetic results, and higher complication rates compared to those treated early. These findings reinforce the critical importance of timely open reduction and internal fixation (ORIF) in achieving optimal anatomical alignment and minimizing long-term morbidity in complex facial trauma [ 1 , 3 , 5 ]. The observed poorer functional outcomes in the delayed group, as measured by the Oral Health Impact Profile (OHIP-14) and Functional Disability Index (FDI), likely stem from biomechanical and biological challenges associated with delayed intervention. Delays allow soft tissue contracture and early bone remodelling, which complicate precise reduction and fixation, leading to suboptimal restoration of occlusion and mastication [ 9 , 12 , 13 ]. For instance, Hermans et al. reported similar findings in maxillofacial fractures, noting that delays beyond 7 days increased the risk of malunion and functional impairment due to fibrosis and callus formation [ 9 ]. Additionally, the higher infection rates (10% vs. 5%) in the delayed group may be attributed to prolonged exposure of fracture sites to oral and nasal flora, particularly in mandibular and midface injuries, which are prone to contamination [ 17 , 19 ]. This aligns with biomechanical studies suggesting that early stabilization minimizes bacterial colonization and promotes bone healing [ 13 , 20 ]. Aesthetic outcomes, assessed via the Facial Aesthetic Index (FAI) and patient satisfaction, were notably worse in the delayed group (FAI: 75 vs. 85). Delayed surgery often results in soft tissue scarring and asymmetry, particularly in the midface, where precise alignment of the zygomatic and naso-orbito-ethmoidal regions is critical for facial symmetry [ 1 , 5 ]. He et al. reported comparable aesthetic challenges in late-treated panfacial fractures, emphasizing the difficulty of restoring pre-injury contours after soft tissue contracture [ 20 ]. The psychological distress observed in the delayed group, including higher rates of chronic pain (28% vs. 15%), further highlights the long-term burden of suboptimal aesthetic outcomes. Levine et al. noted that facial disfigurement significantly impacts quality of life, contributing to social stigma and reduced self-esteem, particularly in younger patients [ 20 ]. This psychosocial burden is especially relevant in resource-limited settings, where access to mental health support is often limited [ 8 , 11 ]. The predominance of road traffic accidents (RTAs) as the primary injury mechanism (82%) mirrors trauma patterns across India and other low- and middle-income countries (LMICs), where inadequate road safety infrastructure and high vehicular density exacerbate facial trauma incidence [ 14 – 16 ]. Mathur et al. reported that RTAs account for over 70% of maxillofacial injuries in India, underscoring the need for targeted public health interventions, such as stricter traffic regulations and helmet mandates [ 14 ]. The high male predominance (88%) in this cohort reflects the demographic patterns of RTA victims, who are often young males engaged in high-risk activities like motorbike riding [ 16 , 19 ]. Socioeconomic disadvantage and poor hygiene emerged as independent predictors of adverse outcomes, consistent with literature linking poverty to delayed healthcare access and increased complication rates [ 7 , 17 ]. Adebayo et al. found that patients in resource-limited settings, such as Nigeria, often present late due to financial constraints, limited transportation, or lack of awareness, leading to higher rates of infection and malunion [ 7 ]. In the present study, patients from lower socioeconomic backgrounds frequently faced delays due to referral bottlenecks and limited access to CT imaging, which is essential for accurate surgical planning [ 6 , 8 ]. These systemic barriers highlight the need for improved trauma care infrastructure in LMICs, including decentralized diagnostic facilities and trained surgical teams [ 11 , 22 ]. The Kaplan–Meier analysis demonstrating higher complication-free survival in the early surgery group supports the biomechanical advantage of timely intervention. Early ORIF minimizes soft tissue oedema and fibrosis, facilitating precise anatomical reduction and reducing the risk of complications like chronic pain and asymmetry [ 20 , 21 ]. This finding is consistent with Strong et al., who emphasized that early stabilization of panfacial fractures optimizes bone healing and reduces long-term morbidity [ 21 ]. However, achieving early intervention in low-resource settings requires overcoming significant logistical challenges, such as shortages of operating theatres and maxillofacial surgeons [ 8 , 22 ]. Comparison with High-Resource Settings In high-resource settings, early ORIF is standard due to robust trauma systems, rapid diagnostic access, and multidisciplinary teams. For example, a study by Salentine et al. in the Netherlands reported complication rates below 5% for panfacial fractures treated within 72 hours, compared to the 12–25% complication rates in our delayed group [ 18 ]. This disparity underscores the impact of systemic constraints in LMICs, where delays are often unavoidable due to resource limitations. Limitations The retrospective design introduces potential selection bias, as patients with delayed surgery may have had more severe injuries or comorbidities not fully captured in medical records. The male predominance (88%) limits generalizability to female patients, who may experience different psychosocial impacts due to cultural factors in India. Additionally, the study did not account for variations in surgical expertise or postoperative rehabilitation, which can influence outcomes. The reliance on a single tertiary center in Western India may not fully represent other LMIC settings with differing healthcare infrastructure. Finally, while AI tools enhanced data extraction and analysis, their use was limited to supportive tasks, and all interpretations were human-driven. Implications for Practice and Policy These findings emphasize the urgent need for system-level interventions to reduce surgical delays in LMICs. Improved trauma triage protocols, such as pre-hospital emergency systems, could expedite patient transfer to specialized centres [ 22 ]. Wider access to CT imaging, potentially through mobile diagnostic units, would enable timely and accurate fracture assessment [ 6 ]. Increasing the surgical workforce through training programs for maxillofacial surgeons and establishing regional trauma centres could address capacity shortages [ 24 ]. Streamlined referral networks, supported by telemedicine, could reduce delays caused by inter-hospital transfers [ 11 ]. Furthermore, integrating multidisciplinary rehabilitation, including physiotherapy and psychological counselling, is critical to address functional and psychosocial sequelae, particularly in patients with delayed surgery [ 20 , 25 ]. Public health campaigns promoting road safety, such as helmet use and speed limits, could reduce the incidence of RTAs, the leading cause of panfacial fractures [ 15 ]. Future Research Prospective multicentre studies are needed to validate these findings across diverse LMIC settings, incorporating standardized surgical protocols and postoperative care. Investigating the role of specific fracture patterns (e.g., mandibular vs. midface) in delayed outcomes could guide tailored interventions. Additionally, studies exploring cost-effective diagnostic tools, such as portable ultrasound for initial fracture assessment, could address imaging barriers in low-resource settings. Finally, longitudinal studies assessing the impact of psychological interventions on recovery in facial trauma patients could inform holistic care models [ 19 ]. Conclusion Delayed surgical intervention (> 7 to ≤ 30 days) in panfacial fractures is associated with poorer functional recovery, compromised aesthetic results, and higher complication rates compared with early intervention. Socioeconomic disadvantage and poor hygiene further compounded outcomes. Early ORIF provides clear survival and quality-of-life benefits, underscoring the need for system-level improvements in trauma pathways, imaging access, and surgical capacity in India. Multidisciplinary rehabilitation, including psychosocial care, should be prioritized to address the full spectrum of patient needs. Declarations Ethical Considerations This retrospective study utilized de-identified data from medical records, with no primary data collection involving human or animal subjects; thus, ethical clearance from an Institutional Review Board was not required. Artificial intelligence and computer tools were used to assist in data extraction, statistical calculations, and drafting sections of the manuscript to enhance accuracy and efficiency. All intellectual contributions, including study design, data interpretation, and conclusions, were made by the authors. The study adhered to the Declaration of Helsinki and was approved by the institutional research committee. All authors contributed significantly, reviewed, and approved the final manuscript. No conflicts of interest are declared [ 25 ]. References Manson PN, Clark N, Robertson B, Slezak S, Wheatly M, Vander Kolk C et al (1999) Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg 103(4):1287–1307. 10.1097/00006534-199904040-00001 Gruss JS, Phillips JH (1989) Complex facial fractures: the evolving role of rigid fixation and immediate bone grafting. Clin Plast Surg 16(1):93–104 PMID:2646315 Ellis E, Muniz O, Anand K (2003) Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 61(8):861–870. 10.1016/S0278-2391(03)00412-9 Bali RK, Sharma P, Garg A, Dhillon G (2013) A comprehensive study on maxillofacial trauma in a tertiary care hospital in North India. J Maxillofac Oral Surg 12(1):89–93. 10.1007/s12663-012-0373-7 Markowitz BL, Manson PN (1989) Panfacial fractures: organization of treatment. Clin Plast Surg 16(1):105–114 PMID:2646316 Chukwulebe S, Hogrefe C (2019) The diagnosis and management of facial bone fractures. Emerg Med Clin North Am 37(1):137–151. 10.1016/j.emc.2018.09.008 Adebayo ET, Ajike SO, Adekeye EO (2003) Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 41(6):396–400. 10.1016/S0266-4356(03)00141-3 Shah I (2019) Update on the management of craniomaxillofacial trauma in low-resource settings. Craniomaxillofac Trauma Reconstr 12(4):259–265. 10.1055/s-0039-1693053 Hermans RA, Buitendijk EJ, van der Vlies CH (2017) Delayed treatment of maxillofacial fractures: a retrospective analysis. Eur J Trauma Emerg Surg 43(4):497–503. 10.1007/s00068-016-0682-6 World Health Organization (2014) Injuries and violence: the facts 2014. WHO, Geneva Deininger C, Hallermann W, Kämmerer PW (2024) Enhancing cranio-maxillofacial fracture care in low- and middle-income countries: a systematic review. Int J Oral Maxillofac Surg 53(4):456–464. 10.1016/j.ijom.2023.09.008 Lee KH (2009) Early versus delayed treatment of mandibular fractures: a comparison of outcomes. Int J Oral Maxillofac Surg 38(8):835–840. 10.1016/j.ijom.2009.03.708 Dal Santo F, Ellis E, Throckmorton GS (1992) The effects of delayed fixation on the biomechanics of mandibular fractures. J Oral Maxillofac Surg 50(8):788–793. 10.1016/0278-2391(92)90268-F Mathur AK, Gupta V, Sharma R (2019) Epidemiology of road traffic accidents in India: a review. J Inj Violence Res 11(2):159–166. 10.5249/jivr.v11i2.1061 World Health Organization (2018) Global status report on road safety 2018. WHO, Geneva Gururaj G (2008) Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J India 21(1):14–20 PMID:18472698 Al-Dajani M (2019) Access to dental care among adults with facial trauma. J Oral Maxillofac Surg 77(6):1245–1252. 10.1016/j.joms.2018.12.026 Salentijn EG, van den Bergh B, Forouzanfar T (2013) A ten-year analysis of midfacial fractures. J Craniomaxillofac Surg 41(7):630–636. 10.1016/j.jcms.2012.12.001 Motamedi MH (2003) An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 61(1):61–64. 10.1053/joms.2003.50048 Levine E, Degutis L, Pruzinsky T, Shin J, Persing J, Sabbagh M (2005) Quality of life and facial trauma: psychological and body image effects. Ann Plast Surg 54(5):502–510. 10.1097/01.sap.0000155279.15342.13 He D, Zhang Y, Ellis E (2007) Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg 65(12):2459–2465. 10.1016/j.joms.2006.11.039 Strong EB, Sykes JM (1998) Management of panfacial fractures: a review. Facial Plast Surg 14(1):53–60. 10.1055/s-0028-1085322 Cheema SA, Amin F (2010) Challenges in the management of maxillofacial injuries in a developing country. J Pak Med Assoc 60(6):429–432 PMID:20527653 Peleg M, Sawatari Y, Tardieu PB (2011) Multidisciplinary management of complex craniofacial trauma. J Craniofac Surg 22(4):1273–1277. 10.1097/SCS.0b013e31821ccbc2 Bisson JI, Shepherd JP, Dhutia M (1997) Psychological sequelae of facial trauma. J Trauma 43(3):496–500. 10.1097/00005373-199709000-00021 Tables Table 1. Patient Demographics and Injury Characteristics (N = 120) Variable Total (N=120) Early Surgery (n=54) Delayed Surgery (n=66) Mean Age (years ± SD) 32 ± 10 31 ± 9 33 ± 11 Male (%) 88% 85% 90% Mechanism of Injury Road Traffic Accidents 82% 83% 80% Assaults 12% 11% 13% Falls 6% 6% 7% Fracture Patterns Frontal fractures 38% 37% 39% Naso-orbito-ethmoidal 45% 44% 46% Zygomatic 62% 63% 61% Mandibular 78% 77% 79% Table 2. Functional and Aesthetic Outcomes at 12 Months Outcome Measure Early Surgery (≤7 days) Delayed Surgery (>7–30 days) p-value OHIP-14 (mean ± SD) 12.5 ± (—) 18.7 ± (—) <0.001 Functional Disability Index 15.3 ± (—) 20.1 ± (—) <0.001 Facial Aesthetic Index (0–100) 85 ± (—) 75 ± (—) <0.01 Patient Satisfaction (Likert) Higher Lower <0.05 Table 3. Complications by Surgical Timing Complication Early Surgery (n=54) Delayed Surgery (n=66) Asymmetry 12% 25% Chronic Pain 15% 28% Infection 5% 10% Any Complication ~20% ~35% Table 4. Predictors of Poor Outcomes (Logistic Regression) Predictor Odds Ratio (OR) 95% CI p-value Delayed Surgery 2.3 1.5 – 3.6 <0.01 Socioeconomic Disadvantage 1.8 1.2 – 2.9 <0.05 Poor Hygiene 2.1 1.3 – 3.4 <0.01 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7545726","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":510883839,"identity":"45b8dc48-7cd0-4fe3-9b73-93b1941c7f1b","order_by":0,"name":"Chandrashekhar Chattopadhyay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACCQgpZ3//8AEQQ4YYLYwNBxgsjBlusCWAuDzEaqlIbLjBYwDiE9bCP7v5+eMPFRKJjbN7Pr+6UWPBw8B++OgGvJbcOWbYcOCMhHGzzNlt1jnHgA7jSUu7gU+LgUSCYcPBNgnZNobcbcY5bEAtEjxmBLSkfwRpYexhyHlmnPOPKC05YFsUZ0jkMD/ObSNCi8SNnMIZZ4B+MeA5Zsac2yfBw0bIL/wz0jd8qKiokzNgb378OedbnRw/++FjeLUgAzZwSmAjVjkIMH8gRfUoGAWjYBSMHAAAKBJKndMqf/sAAAAASUVORK5CYII=","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":true,"prefix":"","firstName":"Chandrashekhar","middleName":"","lastName":"Chattopadhyay","suffix":""},{"id":510884112,"identity":"7a4ca030-0c0c-4e38-a12d-6a3e8af448be","order_by":1,"name":"Vikas Deo","email":"","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Vikas","middleName":"","lastName":"Deo","suffix":""},{"id":510884113,"identity":"8e46b149-fb47-4303-b2f8-cbfe2607e0e0","order_by":2,"name":"Charu Chouhan","email":"","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Charu","middleName":"","lastName":"Chouhan","suffix":""},{"id":510884114,"identity":"60025517-de25-41c4-bf6c-413aafebfd9b","order_by":3,"name":"Mamta Patel","email":"","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Mamta","middleName":"","lastName":"Patel","suffix":""},{"id":510884115,"identity":"e23ed67e-e5d6-46bc-afc8-5a999a6cd4bb","order_by":4,"name":"Ayush Garg","email":"","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Ayush","middleName":"","lastName":"Garg","suffix":""},{"id":510884116,"identity":"b496a5fc-42e1-4df8-9630-369b366fd4e0","order_by":5,"name":"Piriti Airun","email":"","orcid":"","institution":"Dr SN Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Piriti","middleName":"","lastName":"Airun","suffix":""}],"badges":[],"createdAt":"2025-09-05 15:45:36","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7545726/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7545726/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90939465,"identity":"85969b50-a6d8-46e2-9c13-cfa3b3f38097","added_by":"auto","created_at":"2025-09-09 17:50:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23026,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eKaplan–Meier survival plot with 95% confidence intervals\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003e(shaded bands) and censoring events (shown as “+” marks)\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"GA.png","url":"https://assets-eu.researchsquare.com/files/rs-7545726/v1/1afc3c19453c1061d38b2550.png"},{"id":90940314,"identity":"61505d65-95ce-4734-8e8d-2f51fd950f4c","added_by":"auto","created_at":"2025-09-09 17:58:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":156452,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eFunctional (OHIP-14, FDI) and aesthetic (FAI) score trends at 6 and 12 months\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003efor early vs. delayed surgery groups\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7545726/v1/ae1b30e7380822de8e772eb7.png"},{"id":90939469,"identity":"cb25254e-6007-45f2-b83c-4b831b9b515c","added_by":"auto","created_at":"2025-09-09 17:50:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75437,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7545726/v1/179fb2f2349a9bef75ddc299.png"},{"id":90941042,"identity":"d30e085d-6a3f-472d-a73b-1c2a05c136ab","added_by":"auto","created_at":"2025-09-09 18:14:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1073891,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7545726/v1/3169fd87-16af-4872-aa6e-ec03d1aa924d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eImpact of Delayed Surgery on Outcomes of Panfacial Fractures in Low-Resource Healthcare Settings: A Retrospective Cohort Study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePanfacial fractures, defined as simultaneous involvement of at least two of the upper, mid, and lower thirds of the facial skeleton, remain among the most complex challenges in maxillofacial surgery. These injuries, usually caused by high-energy trauma such as road traffic accidents (RTAs), assaults, or falls, compromise mastication, speech, and aesthetics, often requiring immediate intervention to restore anatomical alignment and function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOpen reduction and internal fixation (ORIF) within the first week is widely regarded as the standard of care, providing optimal restoration of symmetry, occlusion, and psychosocial recovery [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, in resource-limited settings such as many regions of India, delays are common due to limited imaging facilities, shortages of specialized surgical teams, and referral delays [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Such delays may worsen outcomes through infection, malunion, scarring, and long-term psychological distress [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough early intervention is emphasized in global literature, few studies from low- and middle-income countries have quantified the impact of delayed surgery in panfacial fractures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This study aims to assess functional, aesthetic, and psychological outcomes in patients undergoing early versus delayed surgical repair at a tertiary care centre in India.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective cohort study reviewed 120 adults (aged 18\u0026ndash;65 years) treated for panfacial fractures at a tertiary centre in Western India from January 2022 to June 2025. Panfacial fractures were defined as injuries involving at least two of the upper (frontal), mid (naso-orbito-ethmoidal, zygomatic), and lower (mandibular) facial regions, confirmed by computed tomography (CT). Patients were grouped by surgical timing: early (\u0026le;\u0026thinsp;7 days post-injury) or delayed (\u0026gt;\u0026thinsp;7 to \u0026le;\u0026thinsp;30 days). Cases beyond 30 days were excluded to avoid secondary deformities requiring different management [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eData were extracted from medical records, including demographics, injury mechanism (e.g., RTAs, assaults), fracture patterns, and surgical details. Outcomes included functional measures (Oral Health Impact Profile [OHIP-14], Functional Disability Index [FDI]), aesthetic outcomes (Facial Aesthetic Index [FAI], patient satisfaction via Likert scale), and complications (e.g., infection, asymmetry, chronic pain). Follow-up was conducted at 1-, 6-, and 12-months post-surgery [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStatistical analyses included t-tests for continuous outcomes (e.g., OHIP-14, FDI, FAI scores), chi-square tests for categorical outcomes (e.g., complication rates), logistic regression to identify predictors of poor outcomes, and Kaplan\u0026ndash;Meier survival analysis for complication-free survival. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. Data were analysed using SPSS version 26 [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf 120 patients (88% male, mean age 32\u0026thinsp;\u0026plusmn;\u0026thinsp;10 years), 54 (45%) underwent early surgery (\u0026le;\u0026thinsp;7 days) and 66 (55%) delayed surgery (\u0026gt;\u0026thinsp;7 to \u0026le;\u0026thinsp;30 days). RTAs were the primary cause (82%), followed by assaults (12%) and falls (6%). Fracture patterns included combinations of frontal (38%), naso-orbito-ethmoidal (45%), zygomatic (62%), and mandibular (78%) injuries [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. \u003cb\u003eTABLE 1\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt 12 months, delayed surgery was associated with significantly worse functional outcomes (OHIP-14: 18.7 vs. 12.5; FDI: 20.1 vs. 15.3; both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower aesthetic scores (FAI: 75 vs. 85; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and higher complication rates, including asymmetry (25% vs. 12%), chronic pain (28% vs. 15%), and infection (10% vs. 5%) [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003cb\u003eTABLE 2\u0026amp; TABLE 3, Fig.\u0026nbsp;2\u003c/b\u003e Logistic regression identified delayed surgery (OR 2.3, 95% CI 1.5\u0026ndash;3.6), socioeconomic disadvantage, and poor hygiene as independent predictors of adverse outcomes \u003cb\u003eTABLE 4\u003c/b\u003e\u0026amp; \u003cb\u003eFig.\u0026nbsp;3\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eKaplan\u0026ndash;Meier analysis showed higher complication-free survival in the early surgery group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Figure\u0026nbsp;1\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective cohort study underscores the detrimental impact of surgical delays beyond 7 days, but within 30 days, on outcomes in panfacial fractures, with patients in the delayed surgery group experiencing significantly worse functional recovery, aesthetic results, and higher complication rates compared to those treated early. These findings reinforce the critical importance of timely open reduction and internal fixation (ORIF) in achieving optimal anatomical alignment and minimizing long-term morbidity in complex facial trauma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe observed poorer functional outcomes in the delayed group, as measured by the Oral Health Impact Profile (OHIP-14) and Functional Disability Index (FDI), likely stem from biomechanical and biological challenges associated with delayed intervention. Delays allow soft tissue contracture and early bone remodelling, which complicate precise reduction and fixation, leading to suboptimal restoration of occlusion and mastication [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For instance, Hermans et al. reported similar findings in maxillofacial fractures, noting that delays beyond 7 days increased the risk of malunion and functional impairment due to fibrosis and callus formation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, the higher infection rates (10% vs. 5%) in the delayed group may be attributed to prolonged exposure of fracture sites to oral and nasal flora, particularly in mandibular and midface injuries, which are prone to contamination [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This aligns with biomechanical studies suggesting that early stabilization minimizes bacterial colonization and promotes bone healing [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAesthetic outcomes, assessed via the Facial Aesthetic Index (FAI) and patient satisfaction, were notably worse in the delayed group (FAI: 75 vs. 85). Delayed surgery often results in soft tissue scarring and asymmetry, particularly in the midface, where precise alignment of the zygomatic and naso-orbito-ethmoidal regions is critical for facial symmetry [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. He et al. reported comparable aesthetic challenges in late-treated panfacial fractures, emphasizing the difficulty of restoring pre-injury contours after soft tissue contracture [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The psychological distress observed in the delayed group, including higher rates of chronic pain (28% vs. 15%), further highlights the long-term burden of suboptimal aesthetic outcomes. Levine et al. noted that facial disfigurement significantly impacts quality of life, contributing to social stigma and reduced self-esteem, particularly in younger patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This psychosocial burden is especially relevant in resource-limited settings, where access to mental health support is often limited [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe predominance of road traffic accidents (RTAs) as the primary injury mechanism (82%) mirrors trauma patterns across India and other low- and middle-income countries (LMICs), where inadequate road safety infrastructure and high vehicular density exacerbate facial trauma incidence [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Mathur et al. reported that RTAs account for over 70% of maxillofacial injuries in India, underscoring the need for targeted public health interventions, such as stricter traffic regulations and helmet mandates [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The high male predominance (88%) in this cohort reflects the demographic patterns of RTA victims, who are often young males engaged in high-risk activities like motorbike riding [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocioeconomic disadvantage and poor hygiene emerged as independent predictors of adverse outcomes, consistent with literature linking poverty to delayed healthcare access and increased complication rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Adebayo et al. found that patients in resource-limited settings, such as Nigeria, often present late due to financial constraints, limited transportation, or lack of awareness, leading to higher rates of infection and malunion [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the present study, patients from lower socioeconomic backgrounds frequently faced delays due to referral bottlenecks and limited access to CT imaging, which is essential for accurate surgical planning [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These systemic barriers highlight the need for improved trauma care infrastructure in LMICs, including decentralized diagnostic facilities and trained surgical teams [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Kaplan\u0026ndash;Meier analysis demonstrating higher complication-free survival in the early surgery group supports the biomechanical advantage of timely intervention. Early ORIF minimizes soft tissue oedema and fibrosis, facilitating precise anatomical reduction and reducing the risk of complications like chronic pain and asymmetry [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This finding is consistent with Strong et al., who emphasized that early stabilization of panfacial fractures optimizes bone healing and reduces long-term morbidity [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, achieving early intervention in low-resource settings requires overcoming significant logistical challenges, such as shortages of operating theatres and maxillofacial surgeons [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eComparison with High-Resource Settings\u003c/strong\u003e\u003cp\u003eIn high-resource settings, early ORIF is standard due to robust trauma systems, rapid diagnostic access, and multidisciplinary teams. For example, a study by Salentine et al. in the Netherlands reported complication rates below 5% for panfacial fractures treated within 72 hours, compared to the 12\u0026ndash;25% complication rates in our delayed group [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This disparity underscores the impact of systemic constraints in LMICs, where delays are often unavoidable due to resource limitations.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cp\u003eThe retrospective design introduces potential selection bias, as patients with delayed surgery may have had more severe injuries or comorbidities not fully captured in medical records. The male predominance (88%) limits generalizability to female patients, who may experience different psychosocial impacts due to cultural factors in India. Additionally, the study did not account for variations in surgical expertise or postoperative rehabilitation, which can influence outcomes. The reliance on a single tertiary center in Western India may not fully represent other LMIC settings with differing healthcare infrastructure. Finally, while AI tools enhanced data extraction and analysis, their use was limited to supportive tasks, and all interpretations were human-driven.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eImplications for Practice and Policy\u003c/strong\u003e\u003cp\u003eThese findings emphasize the urgent need for system-level interventions to reduce surgical delays in LMICs. Improved trauma triage protocols, such as pre-hospital emergency systems, could expedite patient transfer to specialized centres [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Wider access to CT imaging, potentially through mobile diagnostic units, would enable timely and accurate fracture assessment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Increasing the surgical workforce through training programs for maxillofacial surgeons and establishing regional trauma centres could address capacity shortages [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Streamlined referral networks, supported by telemedicine, could reduce delays caused by inter-hospital transfers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, integrating multidisciplinary rehabilitation, including physiotherapy and psychological counselling, is critical to address functional and psychosocial sequelae, particularly in patients with delayed surgery [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Public health campaigns promoting road safety, such as helmet use and speed limits, could reduce the incidence of RTAs, the leading cause of panfacial fractures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFuture Research\u003c/strong\u003e\u003cp\u003eProspective multicentre studies are needed to validate these findings across diverse LMIC settings, incorporating standardized surgical protocols and postoperative care. Investigating the role of specific fracture patterns (e.g., mandibular vs. midface) in delayed outcomes could guide tailored interventions. Additionally, studies exploring cost-effective diagnostic tools, such as portable ultrasound for initial fracture assessment, could address imaging barriers in low-resource settings. Finally, longitudinal studies assessing the impact of psychological interventions on recovery in facial trauma patients could inform holistic care models [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDelayed surgical intervention (\u0026gt;\u0026thinsp;7 to \u0026le;\u0026thinsp;30 days) in panfacial fractures is associated with poorer functional recovery, compromised aesthetic results, and higher complication rates compared with early intervention. Socioeconomic disadvantage and poor hygiene further compounded outcomes. Early ORIF provides clear survival and quality-of-life benefits, underscoring the need for system-level improvements in trauma pathways, imaging access, and surgical capacity in India. Multidisciplinary rehabilitation, including psychosocial care, should be prioritized to address the full spectrum of patient needs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study utilized de-identified data from medical records, with no primary data collection involving human or animal subjects; thus, ethical clearance from an Institutional Review Board was not required. Artificial intelligence and computer tools were used to assist in data extraction, statistical calculations, and drafting sections of the manuscript to enhance accuracy and efficiency. All intellectual contributions, including study design, data interpretation, and conclusions, were made by the authors. The study adhered to the Declaration of Helsinki and was approved by the institutional research committee. All authors contributed significantly, reviewed, and approved the final manuscript. No conflicts of interest are declared [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eManson PN, Clark N, Robertson B, Slezak S, Wheatly M, Vander Kolk C et al (1999) Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg 103(4):1287\u0026ndash;1307. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00006534-199904040-00001\u003c/span\u003e\u003cspan address=\"10.1097/00006534-199904040-00001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGruss JS, Phillips JH (1989) Complex facial fractures: the evolving role of rigid fixation and immediate bone grafting. Clin Plast Surg 16(1):93\u0026ndash;104 PMID:2646315\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEllis E, Muniz O, Anand K (2003) Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 61(8):861\u0026ndash;870. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0278-2391(03)00412-9\u003c/span\u003e\u003cspan address=\"10.1016/S0278-2391(03)00412-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBali RK, Sharma P, Garg A, Dhillon G (2013) A comprehensive study on maxillofacial trauma in a tertiary care hospital in North India. J Maxillofac Oral Surg 12(1):89\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12663-012-0373-7\u003c/span\u003e\u003cspan address=\"10.1007/s12663-012-0373-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarkowitz BL, Manson PN (1989) Panfacial fractures: organization of treatment. Clin Plast Surg 16(1):105\u0026ndash;114 PMID:2646316\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChukwulebe S, Hogrefe C (2019) The diagnosis and management of facial bone fractures. Emerg Med Clin North Am 37(1):137\u0026ndash;151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.emc.2018.09.008\u003c/span\u003e\u003cspan address=\"10.1016/j.emc.2018.09.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdebayo ET, Ajike SO, Adekeye EO (2003) Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 41(6):396\u0026ndash;400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0266-4356(03)00141-3\u003c/span\u003e\u003cspan address=\"10.1016/S0266-4356(03)00141-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShah I (2019) Update on the management of craniomaxillofacial trauma in low-resource settings. Craniomaxillofac Trauma Reconstr 12(4):259\u0026ndash;265. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0039-1693053\u003c/span\u003e\u003cspan address=\"10.1055/s-0039-1693053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHermans RA, Buitendijk EJ, van der Vlies CH (2017) Delayed treatment of maxillofacial fractures: a retrospective analysis. Eur J Trauma Emerg Surg 43(4):497\u0026ndash;503. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00068-016-0682-6\u003c/span\u003e\u003cspan address=\"10.1007/s00068-016-0682-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2014) Injuries and violence: the facts 2014. WHO, Geneva\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeininger C, Hallermann W, K\u0026auml;mmerer PW (2024) Enhancing cranio-maxillofacial fracture care in low- and middle-income countries: a systematic review. Int J Oral Maxillofac Surg 53(4):456\u0026ndash;464. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijom.2023.09.008\u003c/span\u003e\u003cspan address=\"10.1016/j.ijom.2023.09.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee KH (2009) Early versus delayed treatment of mandibular fractures: a comparison of outcomes. Int J Oral Maxillofac Surg 38(8):835\u0026ndash;840. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijom.2009.03.708\u003c/span\u003e\u003cspan address=\"10.1016/j.ijom.2009.03.708\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDal Santo F, Ellis E, Throckmorton GS (1992) The effects of delayed fixation on the biomechanics of mandibular fractures. J Oral Maxillofac Surg 50(8):788\u0026ndash;793. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/0278-2391(92)90268-F\u003c/span\u003e\u003cspan address=\"10.1016/0278-2391(92)90268-F\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMathur AK, Gupta V, Sharma R (2019) Epidemiology of road traffic accidents in India: a review. J Inj Violence Res 11(2):159\u0026ndash;166. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5249/jivr.v11i2.1061\u003c/span\u003e\u003cspan address=\"10.5249/jivr.v11i2.1061\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2018) Global status report on road safety 2018. WHO, Geneva\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGururaj G (2008) Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J India 21(1):14\u0026ndash;20 PMID:18472698\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Dajani M (2019) Access to dental care among adults with facial trauma. J Oral Maxillofac Surg 77(6):1245\u0026ndash;1252. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.joms.2018.12.026\u003c/span\u003e\u003cspan address=\"10.1016/j.joms.2018.12.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalentijn EG, van den Bergh B, Forouzanfar T (2013) A ten-year analysis of midfacial fractures. J Craniomaxillofac Surg 41(7):630\u0026ndash;636. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jcms.2012.12.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jcms.2012.12.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMotamedi MH (2003) An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 61(1):61\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/joms.2003.50048\u003c/span\u003e\u003cspan address=\"10.1053/joms.2003.50048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevine E, Degutis L, Pruzinsky T, Shin J, Persing J, Sabbagh M (2005) Quality of life and facial trauma: psychological and body image effects. Ann Plast Surg 54(5):502\u0026ndash;510. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.sap.0000155279.15342.13\u003c/span\u003e\u003cspan address=\"10.1097/01.sap.0000155279.15342.13\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe D, Zhang Y, Ellis E (2007) Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg 65(12):2459\u0026ndash;2465. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.joms.2006.11.039\u003c/span\u003e\u003cspan address=\"10.1016/j.joms.2006.11.039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStrong EB, Sykes JM (1998) Management of panfacial fractures: a review. Facial Plast Surg 14(1):53\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0028-1085322\u003c/span\u003e\u003cspan address=\"10.1055/s-0028-1085322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheema SA, Amin F (2010) Challenges in the management of maxillofacial injuries in a developing country. J Pak Med Assoc 60(6):429\u0026ndash;432 PMID:20527653\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeleg M, Sawatari Y, Tardieu PB (2011) Multidisciplinary management of complex craniofacial trauma. J Craniofac Surg 22(4):1273\u0026ndash;1277. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SCS.0b013e31821ccbc2\u003c/span\u003e\u003cspan address=\"10.1097/SCS.0b013e31821ccbc2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBisson JI, Shepherd JP, Dhutia M (1997) Psychological sequelae of facial trauma. J Trauma 43(3):496\u0026ndash;500. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00005373-199709000-00021\u003c/span\u003e\u003cspan address=\"10.1097/00005373-199709000-00021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Patient Demographics and Injury Characteristics (N = 120)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"491\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (N=120)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly Surgery (n=54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed Surgery (n=66)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean Age (years ± SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e32 ± 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e31 ± 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33 ± 11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMale (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e88%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanism of Injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRoad Traffic Accidents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAssaults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;Falls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFracture Patterns\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFrontal fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;Naso-orbito-ethmoidal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e46%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eZygomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMandibular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Functional and Aesthetic Outcomes at 12 Months\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"548\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly Surgery (≤7 days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed Surgery (\u0026gt;7–30 days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOHIP-14 (mean ± SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.5 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18.7 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFunctional Disability Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15.3 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e20.1 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFacial Aesthetic Index (0–100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e85 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e75 ± (—)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003ePatient Satisfaction (Likert)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHigher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Complications by Surgical Timing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"463\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly Surgery (n=54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelayed Surgery (n=66)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAsymmetry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eChronic Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAny Complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e~20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e~35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Predictors of Poor Outcomes (Logistic Regression)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"519\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDelayed Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.5 – 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSocioeconomic Disadvantage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.2 – 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003ePoor Hygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.3 – 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Dr SN Medical College Jodhpur","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Panfacial fractures, delayed surgery, functional outcomes, aesthetic outcomes, trauma care, resource-limited settings","lastPublishedDoi":"10.21203/rs.3.rs-7545726/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7545726/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Panfacial fractures, involving simultaneous injuries to the upper, mid, and lower facial skeleton, pose significant challenges due to their complexity. Timely surgical intervention is critical for optimal functional and aesthetic outcomes, yet delays are common in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To assess the impact of delayed surgical treatment on outcomes in patients with panfacial fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective cohort study reviewed 120 adults (aged 18–65 years) treated for panfacial fractures at a tertiary centre in Western India from January 2022 to June 2025. Fractures included combinations of frontal, Naso-orbito-ethmoidal, zygomatic, and mandibular injuries. Patients were grouped by surgical timing: early (≤7 days post-injury) or delayed (\u0026gt;7 to ≤30 days). Cases beyond 30 days were excluded to avoid secondary deformities. Outcomes evaluated included function (Oral Health Impact Profile, Functional Disability Index), aesthetics (Facial Aesthetic Index, patient satisfaction), and complications (e.g., asymmetry, chronic pain). Statistical analyses used t-tests, chi-square tests, logistic regression, and Kaplan–Meier survival analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 120 patients (88% male, mean age 32 ± 10 years), 54 (45%) underwent early surgery and 66 (55%) delayed surgery, primarily due to road traffic accidents (82%). Delayed surgery was associated with worse functional outcomes (OHIP-14: 18.7 vs. 12.5; FDI: 20.1 vs. 15.3; both p\u0026lt;0.001), reduced aesthetic scores (FAI: 75 vs. 85; p\u0026lt;0.01), and higher rates of complications, including asymmetry (25% vs. 12%) and chronic pain (28% vs. 15%). Delayed surgery independently predicted adverse outcomes (OR 2.3, 95% CI 1.5–3.6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Surgical delays beyond 7 days significantly impair outcomes in panfacial fractures. Enhanced trauma care systems are vital to ensure timely surgery in low-resource settings.\u003c/p\u003e","manuscriptTitle":"Impact of Delayed Surgery on Outcomes of Panfacial Fractures in Low-Resource Healthcare Settings: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 17:50:20","doi":"10.21203/rs.3.rs-7545726/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac1a45a0-d21e-4d82-8b5a-9c3b5fdc72f4","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54270955,"name":"Dentistry"}],"tags":[],"updatedAt":"2025-09-09T17:50:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 17:50:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7545726","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7545726","identity":"rs-7545726","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}