Epidemiology of Maxillofacial Fractures and Concomitant Injuries in a Craniofacial Unit: A Retrospective Study
A Devadiga, K Prasad
concomitant injuries, epidemiology, maxillofacial injuries, retrospective
A Devadiga, K Prasad. Epidemiology of Maxillofacial Fractures and Concomitant Injuries in a Craniofacial Unit: A Retrospective Study. The Internet Journal of Epidemiology. 2007 Volume 5 Number 2.
Department and institution to which work is credited
Department of Community Dentistry,
S.D.M College of Dental Sciences and Hospital,
Karnataka state, India
The human face is the first focus of human interaction and a source of man's fascination with the idea of beauty. Ironically, the facial area is one of the most frequently injured areas of the body.
Injuries accounted for 9% of the world's deaths and 12% of the world's burden of disease in the year 2000. More than 90% of the world's deaths from injuries occur in low and middle-income countries 1 .
Hence, the following study aimed to collect information regarding the epidemiology of oral and maxillofacial fractures and concomitant injuries from the Craniofacial Unit (CFU) of S.D.M. College of Dental Sciences, Dharwad as it serves as a tertiary referral centre for the entire Dharwad district and adjacent areas. The objectives were: 1) Review the maxillofacial fractures treated in the CFU over a period of 5 yrs retrospectively, by assessing patient records. 2) Identify patterns of maxillofacial fractures. 3) Identify concomitant injuries and 4) Assess the extent of postoperative complications.
A descriptive retrospective study was conducted to investigate the epidemiological characteristics of maxillofacial fractures and concomitant injuries in patients admitted to the Craniofacial Unit, S.D.M. College of Dental Sciences and Hospital, Dharwad. The records of patients who were admitted to the unit over a period of 5 yrs, i.e., between 1 st January 2001 and December 31 st 2005 were accessed for the purpose of the present study. The records prior to this date were not assessed due to lack of completeness and availability.
Information relevant to the study was accessed by manually perusing case records of patients after obtaining ethical clearance from the ethical committee of the institution and written permission from the head of the unit.
The anatomic location of the mandibular fractures was classified according to Ivy and Curtis2 , while zygomatic complex fractures were classified as fractures of the arch, body of the zygomatic bone and comminuted fractures. The maxillary fractures were classified as Lefort I, II, and III 3 .
The systems-injuries were grouped into integumental, abdominal, neurological, pulmonary, cardiac, ophthalmologic and orthopedic systems.
The data was entered into the MS-Office Excel 2007 and subjected to statistical analysis using the statistical package – XLSTAT- 2008.
The associations between age, sex, type and cause of fractures was assessed for statistical significance using chi-square test. The level of significance was set at 5%.
A total of 598 records were assessed for the present study. 52% of the patients treated at the unit had received primary care before being referred to the unit. The average duration of hospital stay was 5-9 days.
The patient's ages ranged from 1-78 years, with mean age of 29.65 (SD= 17.27 to 42.03) years. 87.29% (n=522) were males, resulting in a male to female ratio of 7:1.
Irrespective of the cause for trauma, the most affected age group was 21-30yrs, expect for assaults where the affected age group was 31-40 yrs in females.
In case of the mandible, RTA's were responsible for 60% (n=384). Parasymphysis was the most common site affected irrespective of the cause of injury. Mandibular fractures as related to cause of injury was statistically significant (Chi square=33.089 p-value=0.045, df=21).
In the midfacial region 70.51% (n= 220) fractures were caused due to RTA's and falls respectively. In both cases, fractures of the zygomatic complex were the highest at 22.76% (n=71) and 3.85% (n=12). Of the 10.90% (n= 34) caused due to assaults, 1.96% (n=6) comprised of Lefort fractures. Midfacial fractures as related to cause of injury were not found to be statistically significant. (Chi square=24.5 p-value= 0.139 DF=18)
Loss of consciousness contributed to 35.65% (n= 210) of the neurological injuries, and was frequently associated with fractures of the zygomatic complex (32.31%, n= 42) and parasymphysis (48.72%, n= 114) while least with fractures of the zygomatic body and coronoid process at 0.43% (n=1).
The evolution of man has made the frontal regions of the face susceptible to trauma and fractures. Maxillofacial injuries though rarely fatal, are responsible for subjecting tremendous physical and psychological anguish on the affected.
Worldwide differences in the distribution and occurrence of maxillofacial fractures have been stated to be a result of differing socio-economic, cultural and environmental influences 4 .
In the present study the male to female ratio was 7:1, which is in contrast to high ratios in Turkey 5 (25:1) & Nigeria 6 (16.9:1) and low ratios in Jordan 7 (1:1), and Scotland 8 (3:1). Studies, which mimic ratios of our study, were seen Nairobi 9 (8.4:1) and Libya 10 (7:1). The higher preponderance of male subjects could be attributed to the fact that males are the bread earners of the family and work out-doors, likely to be involved in violent conduct, participate in sports, and drive recklessly 4 .
The most commonly affected age was 21-30 yrs which is similar to findings of other studies 6,10,11 , which could be attributed to greater physical activity and self-mobility seen in this group .
In the present study, RTA's constituted the most common cause of injury; similar to studies conducted in Greece 12 and Iran 13 . In contrast, studies conducted in Glasgow 8 and Shimla 14 , found assaults and falls respectively to be more common causes. RTAs as a cause for morbidity and mortality are on the rise in India. Liberalization in the early 90's, rapid urbanization and the improving Indian economy has led to a huge increase in motorization. However, improvements in infrastructure have not kept up with the surge in vehicular traffic on Indian roads. Poor vehicle maintenance, lack of enforcement of traffic rules, poor educational status of the drivers, inadequate trauma care, legislation and political will compound the problem.
Summer months of March, May and June had the highest number of injuries 5,13 . The reason could be good weather conditions for the scheduling of vacations, leading to greater opportunities for outdoor activities and traveling.
Various studies confirmed isolated fractures of the mandible to be the most common bone affected 5,15 . This preponderance could be due to the fact that the mandible is the most prominent and the only moveable facial bone and is fractured more often than the well-articulated midfacial bones. While parasymphysis as the most common site was confirmed by Vetter et al 7 , contrasting results were obtained showing the condyle 15 and body 5 as frequently affected sites.
In the present study, among the fractures of the midfacial region, the zygomatic complex factures were most common followed by Lefort fractures. Similar results were obtained in other studies 6,7,11 . The midfacial region tends to act like a ‘crumple zone' for the cranium and skull base when excessive forces are absorbed 16 .
In the present study, we found fractures of the parasymphysis, the most frequent fractures irrespective of the cause on injury which is in contrast to a study where body of the mandible was the affected site in RTA's and assaults 8 .Review of literature reveals that the most common site of involvement in case of falls was the condyle 17 , which is in contrast with the present study. This could probably be due to the false reporting of fractures due to assaults and/or RTAs as occurring due to falls for fear of reprisal or to avoid medico-legal complications.
The present study illustrated that facial fractures can occur in combination with other injuries, which is corroborated by findings from other studies 6,18,19 . Hence immediate diagnosis and intelligent cooperation of general surgical, orthopedic, plastic, maxillofacial, neurosurgical and ophthalmic and dental teams is of paramount importance.
Multiple fracture patterns serve a neuroprotective function, allowing dissipation of force and resulting in the transmission of less residual energy to the cranial vault. When the jaw sustains fewer or less severe fractures, more forces travel to the vault as the jaw absorbs less energy 20 , thereby leading to loss of consciousness. This was corroborated in the present study where nearly 50% of patients with isolated parasymphyseal fractures suffered from loss of consciousness.
In the present study, open method of fracture reduction was employed in 85.45%, higher than values of 60% found in study by Vetter 7 , 40% by Hosein 21 .
The present study indicated that 32% suffered from post-operative complications, which is higher than that found by Hosein 21 (18%) and lower than that found by Aboise 22 (61.54%). The high rates of infection in the present study could be ascribed to the use of ORIF methods of treatment 16 . Over the 5 yrs the rates of postoperative complications have decreased drastically, which could probably be due to decrease in rates of postoperative infections.
The number of injuries in a region is important not only in the organization of regional trauma services but also for introducing legislation, instituting measures for prevention, assessing the effectiveness of existing preventive measures, audits and conducting new research. In the present study adequate information could not be obtained on some factors like occupation, level of education, drink driving, helmet/seatbelt use, and type of RTAs etc. An appropriate recording format therefore needs to be developed which would enable collection and retrieval of data for future studies more efficient.
Due to continuing changes in the trends of maxillofacial trauma, further epidemiologic studies of facial fractures are essential which might throw additional light on the etiology of maxillofacial fractures and also suggest novel ways of prevention.