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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 28-33

Retrospective study of maxillofacial trauma in Alexandria University: Analysis of 177 cases


Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt

Date of Submission22-Feb-2016
Date of Acceptance17-Jul-2016
Date of Web Publication26-Jul-2016

Correspondence Address:
Lydia N Melek
16 Ahmed Tayseer Street, Asafra Bahary, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-8574.186943

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  Abstract 

Purpose
The aim of the present study was to analyze retrospectively the age and sex distribution, etiology, and location of mandibular and midface fractures in a sample of patients from the Oral and Maxillofacial Surgery Department, Alexandria University, Egypt.
Patients and methods
The data for this study were obtained from the medical records of 177 cases treated at the Oral and Maxillofacial Surgery Department, Alexandria University, from April 2010 to August 2011.
Results
The total number of patients with maxillofacial trauma presenting to the Oral and Maxillofacial Surgery Department, during the period from April 2010 to August 2011 was 177 patients. The male population was more frequently affected compared with the female population, males were more frequently affected than females, where males accounted for 82% (145 patients) and females accounted for 18% (32 patients) of the study population with a ratio of 4.5:1. The ages of the patients in the study population ranged from 1.5 to 75 years, with a mean of 25.56 ΁ 14.04 years. Road traffic accident (RTA) was the most common cause of trauma, accounting for 77.97% (138) of cases. A total of 103 cases had isolated mandibular fractures, 54 cases had midface fractures only, and 20 patients had mandibular fractures associated with midface fractures. The most common site in mandibular fractures was the parasymphysis (40.64%; 63 fractures), and zygomaticomaxillary complex fractures were the most common, accounting for 70.13% (54 fractures) of midface fractures. Most of the fractures were treated by means of open reduction and internal fixation using plates (144 cases; 81.36%), whereas the remaining 33 (18.64%) cases were treated conservatively by means of closed reduction. The duration of hospital stay ranged from 0 to 26 days, with an average of 7.34 ΁ 4.64 days.
Conclusion
RTAs are the main etiological factor in maxillofacial injuries occurring in Alexandria, with men between 21 and 45 years of age being affected predominantly. Preventive strategies remain the best way to reduce the sequelae of RTAs.

Keywords: Alexandria University, maxillofacial trauma, retrospective study, road traffic accident


How to cite this article:
Melek LN, Sharara AA. Retrospective study of maxillofacial trauma in Alexandria University: Analysis of 177 cases. Tanta Dent J 2016;13:28-33

How to cite this URL:
Melek LN, Sharara AA. Retrospective study of maxillofacial trauma in Alexandria University: Analysis of 177 cases. Tanta Dent J [serial online] 2016 [cited 2017 Jun 27];13:28-33. Available from: http://www.tmj.eg.net/text.asp?2016/13/1/28/186943


  Introduction Top


The anatomic location and pattern of maxillofacial fractures are determined by the mechanism of injury and direction of impact. In addition to being anatomically complex, its exposure to the external environment is maximal in comparison with the rest of the human body; such injuries therefore require precise evaluation and treatment [1].

The incidence and etiologies of such facial fractures are chiefly influenced by race and country development. Other influencing factors include geography, culture, social traditions, economic status, level of education, and mode of transportation [1].

The main causes worldwide are assaults and traffic accidents, but the most frequent cause varies from one country to another. Some studies have shown that assault is most common in developing countries, whereas traffic accidents are more common in developed countries [2].

The aim of the present study was to analyze retrospectively the age and sex distribution, etiology, and location of mandibular and midface fractures in a sample of patients from the Oral and Maxillofacial Surgery Department, Alexandria University, Egypt.


  Patients and Methods Top


The data for this study was obtained from the medical records of 177 cases treated at the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Alexandria University, during the period from April 2010 to August 2011. Data collected included sex, age, etiology, fracture area, month in which the trauma occurred, treatment applied, duration of hospital stay, and drug therapy. All patients are informed about the purpose and steps of this research and written consents are signed according to the ethics committee of Faculty of Dentistry, Tanta University.


  Results Top


In this study, the total number of patients with maxillofacial trauma presenting to the Oral and Maxillofacial Surgery Department, Alexandria University, and whose medical records could be retrieved during the period from April 2010 to August 2011 (16 months) was 177 patients. Among these patients, 155 mandibular fractures and 77 midface fractures were reported. The male population was more frequently affected compared with the female population, in which male patients accounted for 82% (145 patients) and female patients accounted for 18% (32 patients) of the study population, with a ratio of 4.5 : 1 ([Figure 1]).
Figure 1: Sex distribution in the study population.

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The ages of the patients affected with maxillofacial trauma in the study population ranged from 1.5 to 75 years, with a mean of 25.56±14.04 years. The most commonly affected age group was that from 21 to 45 years, whereas the least affected was that of patients older than 45 years (([Table 1]) and Figure 2).
Table 1: Age distribution of the study population

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Figure 2: Age distribution in the study population.

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Road traffic accidents (RTAs) were the most common cause of maxillofacial trauma, accounting for 77.97% (138) of cases, followed by assaults and interpersonal violence (14.124%; 25), falls (4.5%; 8), and other injuries (3.39%; 6) ([Figure 3]).
Figure 3: Distribution of trauma etiology in the study population. RTA, road traffic accident.

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Mandibular fractures were detected in 123 patients, whereas midface fractures were seen in 74 patients of the study population. A total of 103 cases had isolated mandibular fractures, 54 cases had midface fractures only, and 20 patients had mandibular fractures associated with midface fractures ([Figure 4]).
Figure 4: Site distribution of trauma cases.

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The order of fracture site from most common to least common in mandibular fractures was parasymphysis (40.64%; 63 fractures), body (21.94%; 34 fractures), angle (16.77%; 26 fractures), condylar and subcondylar fractures (10.97%; 17 fractures), symphysis (6.45%; 10 fractures), ramus (1.9%; 3 fractures), coronoid (0.645%; 1 fracture), and dentoalveolar (0.645%; 1 fracture). In midface fractures, zygomaticomaxillary complex fractures were the most common, accounting for 70.13% (54 fractures), whereas other midfacial fractures (Le fort, nasal, and orbital) accounted for 29.87% (23 fractures) ([Table 2] and [Figure 5] and [Figure 6]). The parasymphyseal fractures represented 27.16% of the overall number of fractures, whereas ZMC fractures accounted for 23.26% of the overall number of fractures.
Table 2: Site distribution of mandibular fractures

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Figure 5: Site distribution of mandibular fractures.

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Figure 6: Site distribution of midface fractures.

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A relationship between the etiology and the site of fracture could be established: the zygomaticomaxillary complex was most frequently involved in 82.5% of the cases caused by RTA, 70% caused by IPV, and 45% caused by falls. In the mandible, the parasymphysis (48 fractures), angle (14 fractures), and condyle (11 fractures) were most affected by RTA. Seven parasymphysis fractures were a result of IPV; however, the angle had lesser predilection (four fractures). The symphysis (six fractures) was maximally affected by falls, followed by the parasymphysis, body, and condyle.

Moreover, a relationship between age and etiology of the fracture can be demonstrated. In children younger than 10 years of age, falls were the cause in 28.6% of cases. In teenagers, IPV accounted for 85% of the cases. However, in older age groups, RTAs represented the main cause of fracture (73.64% of cases).

Most of the fractures were treated by means of open reduction and internal fixation using plates (144 cases; 81.36%), whereas the remaining 33 (18.64%) cases were treated conservatively by means of closed reduction ([Figure 7]). Fractures of the mandibular symphysis, parasymphysis, and body were always stabilized with plates using an intraoral approach, whereas for the angle and ramus regions an extraoral approach was used when indicated. Of 17 condylar fractures, only one was treated with open reduction, whereas the rest were treated by means of closed reduction and MMF for 2 weeks, followed by release of MMF and jaw exercises. Midface fractures were treated using open reduction and fixation using plates through intraoral (vestibular), lateral eyebrow, and subciliary incisions. Adjunctive procedures such as wire suspension and transpalatal wiring were used when indicated.
Figure 7: Types of treatment applied in the study population versus number of cases.

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The duration of hospital stay for all patients from patient admission to patient discharge ranged from 0 to 26 days, with an average of 7.34 ± 4.64 days (the mean for cases treated with closed reduction was 3.36 ± 2.63 days, and the mean for cases treated with open reduction was 8.175 ± 4.52 days). Standard antibiotic–analgesic protocols were followed postoperatively for all patients, and the follow-up period for all patients ranged between 1 and 6 months postoperatively.

The highest number of cases during the study period was recorded in May 2010 (18 cases) and March 2011 (18 cases), whereas the least number was recorded in April and December 2010 (five cases) and January 2011 (three cases) ([Table 3] and Figure 8).
Table 3: Month distribution of Maxillofacial trauma cases from April 2010 to August 2011

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Figure 8: Month distribution of trauma cases during the study period.

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  Discussion Top


Maxillofacial fractures have now become a public health issue in many parts of the world. Epidemiologic surveys in different countries have revealed factors such as geographical location, culture, socioeconomic status, means of transportation, and traffic legislations as influential factors affecting the incidence and etiology of maxillofacial fractures [3].

As for age and sex distribution in the present study, the male population was more frequently affected, accounting for 82% (145), and the female population accounted for just 18% (32), almost attaining a male-to-female ratio of 4.5 : 1. This is in accordance with other studies showing a male predilection in maxillofacial fractures [1],[2]. The ages of the patients in this study ranged from 1.5 to 75 years, with a mean of 25.56±14.04 years. The most commonly affected age group was that from 21 to 45 years. Such individuals (in the third and forth decades of life) are more commonly involved in high-speed driving, less commitment to traffic regulations, altercations, sports, and other outdoor activities compared with older individuals. Vetter et al. [4] observed that the male-to-female ratio was nearly 3 : 1 and the average age was 29.7 years, with a range of 4–82 years. Subhashraj et al. [5] also observed that those between 20 and 29 years of age were more commonly affected (31%) and the male-to-female ratio was 3.7 : 1. Thus, our results are almost in agreement with those of previous studies.

As regards the etiology of maxillofacial trauma, RTAs were the most common cause of maxillofacial trauma, accounting for 77.97% of cases, followed by assaults (14.124%), falls (4.5%), and other injuries (3.39%). Recent studies had established RTA as the leading cause of facial fractures in most developing countries of Africa, Middle East, Asia, and some parts of Europe [6],[7],[8]. In developed nations, progress in technology has resulted in more personal and vehicle protective measures being implemented in addition to access to proper medical care, good road and transport facilities, and regular enforcement of traffic rules and regulations. The reverse scenario exists in developing countries, where entry into opposite traffic lane without regard, violation of the right of the way, violation of the highway code, and some behavioral disorders exist [9]. This applies on our study population, especially immediately after the 25th January revolution in 2011 and the unstable political and social conditions when many traffic rules were violated.

Huelke and Compton [10] stated that motorbike accidents are usually more serious compared with car accidents. Increase in the use of motorbikes has led to a greater number of accidents and, consequently, multiple facial fractures, especially that the riders neglected the habit of wearing a crash helmet.

The anatomic distribution and incidence of maxillofacial fractures are widely variable. Many authors reported the angle as the most frequently affected site in mandibular fractures [11], whereas others reported this to be mandibular body [12] and symphysis [13].

However, in our study, the parasymphysis was the most frequently affected site (40.64%) in the mandible and the ZMC was the most commonly affected (70.13%) in the midface region. This may be due to more severe type of injury in RTAs than in assaults in our study. This is mostly attributed to the fact that usually canines have larger roots, making the mandible anatomically weak in the parasymphyseal region, thus leading to most fractures. In midface fracture, the zygomatic complex is the most commonly affected site, as it is the most prominent portion of the face, and usually during trauma every person has a tendency to show this portion toward the injuring object. Our results are in line with those of other studies by Kamath et al.[1] and Kar and Mahavoi [2] with regard to the pattern and site distribution of maxillofacial fractures.

Maxillofacial fracture incidence in the present study was highest in May 2010, March 2011 (18 cases in each), followed by May (15 cases) and June (16 cases) 2011. March 2011 was a short time after the 25th January revolution when the political and social environment was still unstable with frequent demonstrations, less respect of traffic rules, and increased interpersonal violence. The least number of cases was recorded in January 2011 when curfew was ordered by the authorities, requiring people to stay indoors for a certain number of hours each day. The rate of maxillofacial trauma was also higher during the summer months due to the huge number of people coming from other governorates to spend the summer vacation in Alexandria, the oldest and well-known summer resort in Egypt. Our results are in agreement with the results of other studies in this regard. Kontio et al. [14] in their study found an increase in incidence in June and August, whereas Ravindran and Ravindran Nair [15] reported a significantly high incidence in April and May. Paes et al. [16] suggested that increased maxillofacial trauma during summer holiday is due to availability of more leisure time. Hence, road travel might be compromised, especially with increased density of people in these roads. Kar and Mahavoi [2] have observed that March and December (16.8%) had the highest number of cases of maxillofacial injuries, followed by November (12.6%), whereas the least number was seen in April and September (3.2%).

In general, the protocol for treating all maxillofacial fractures in our department was open reduction and internal fixation using plates to maximally achieve harmonious occlusion and esthetics and optimally restore function. Titanium plate osteosynthesis for facial fracture treatment has gained popularity worldwide and is the gold standard nowadays. However, undisplaced fractures with intact occlusion were amenable to conservative treatment.


  Conclusion Top


RTAs are the main etiological factor in maxillofacial injuries occurring in Alexandria, with men between 21 and 45 years of age being affected predominantly.

Several recommendations are suggested to reduce the incidence of such injuries in our society:

  1. Strict application of road safety legislation and lane discipline
  2. Strict laws to urge motorbike riders to wear protective crash helmets, car drivers to use seat belts, and pedestrians to use only allowed places (pedestrian bridges, tunnels, etc.) for crossing roads, especially those with high-speed vehicles
  3. Legal forbiddance of drunk and addict drivers, especially those driving trucks on highways
  4. Prohibition of using mobile phones while driving
  5. More strict punishment of those who violate traffic rules and regulations.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kamath RAD, Bharani S, Hammannavar R, Ingle S, Shah AG. Maxillofacial trauma in Central Karnataka, India: an outcome of 95 cases in a Regional Trauma Care Centre. Craniomaxillofac Trauma Reconstr 2012; 5:197–204.  Back to cited text no. 1
    
2.
Kar IB, Mahavoi BR. Retrospective analysis of 503 maxillofacial trauma cases in Odisha during the period of Dec'04–Nov'09. J Maxillofac Oral Surg 2012; 11:177–181.  Back to cited text no. 2
    
3.
Gomes PP, Passeri LA, Barbosa JR. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg 2006; 64:63–67.  Back to cited text no. 3
    
4.
Vetter JD, Topazian RG, Goldberg MH, Smith DG. Facial fractures occurring in a medium-sized metropolitan area: recent trends. Int J Oral Maxillofac Surg 1991; 20:214–216.  Back to cited text no. 4
    
5.
Subhashraj K, Nandakumar N, Ravindran C. Review of maxillofacial injuries in Chennai, India: a study of 2748 cases. Br J Oral Maxillofac Surg 2007; 45:637–639.  Back to cited text no. 5
    
6.
Al-Khateeb T, Abdullah FM. Craniomaxillofacial injuries in the United Arab Emirates: a retrospective study. J Oral Maxillofac Surg 2007; 65:1094–1101.  Back to cited text no. 6
    
7.
Ansari MH. Maxillofacial fractures in Hamedan province, Iran: a retrospective study (1987–2001). J Craniomaxillofac Surg 2004; 32:28–34.  Back to cited text no. 7
    
8.
Olasoji HO, Tahir A, Arotiba GT. Changing picture of facial fractures in northern Nigeria. Br J Oral Maxillofac Surg 2002; 40:140–143.  Back to cited text no. 8
    
9.
Malara P, Malara B, Drugacz J. Characteristics of maxillofacial injuries resulting from road traffic accidents: a 5 year review of the case records from Department of Maxillofacial Surgery in Katowice, Poland. Head Face Med 2006; 2:27.  Back to cited text no. 9
    
10.
Huelke DF, Compton CP. Facial injuries in automobile crashes. J Oral Maxillofac Surg 1983; 41:241–244.  Back to cited text no. 10
    
11.
Gabrielli MAC, Gabrielli MFR, Marcantonio E, Hochuli-Vieira E. Fixation of mandibular fractures with 2.0 mm miniplates: review of 191 cases. J Oral Maxillofac Surg 2003; 61:430–436.  Back to cited text no. 11
    
12.
Horibe KE, Pereira MD, Ferreira LM, Andrade EF. Perfil epidemiologico de fracturas mandibulares tratadas na Universidade Federal de sao Paulo-Escola Paulista de Medicina. Rev Assoc Med Bras 2004; 50:417–421.  Back to cited text no. 12
    
13.
Chuong R, Donoff RB, Guralnick WC. A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 1983; 41:305–309.  Back to cited text no. 13
    
14.
Kontio R, Suuronen R, Ponkkonen H, Lindqvist C, Laine P. Have the causes of maxillofacial fractures changed over the last 16 years in Finland? An epidemiological study of 725 fractures. Dent Traumatol 2005; 21:14–19.  Back to cited text no. 14
    
15.
Ravindran V, Ravindran Nair KS. Metaanalysis of maxillofacial trauma in the northern districts of Kerala: one year prospective study. J Maxillofac Oral Surg 2011; 10:321–327.  Back to cited text no. 15
    
16.
Paes JV, de Sá Paes FL, Valiati R, de Oliveira MG, Pagnoncelli RM. Retrospective study of prevalence of face fractures in southern Brazil. Indian J Dent Res 2012; 23:80–86.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

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