Aetiology of maxillofacial fractures: a review of published studies during the last 30 years

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British Journal of Oral and Maxillofacial Surgery 52 (2014) 901–906

Review

Aetiology of maxillofacial fractures: a review of published studies during the last 30 years Paolo Boffano ∗ , Sofie C. Kommers, K. Hakki Karagozoglu, Tymour Forouzanfar Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB Amsterdam, The Netherlands Accepted 14 August 2014 Available online 15 September 2014

Abstract The epidemiology of facial trauma may vary widely across countries (and even within the same country), and is dependent on several cultural and socioeconomic factors. We know of few reviews of published reports that have considered the sex distribution and aetiology of maxillofacial trauma throughout the world. The aim of this review was to discuss these aspects as they have been presented in papers published during the last 30 years. We made a systematic review of papers about the epidemiology of maxillofacial trauma that were published between January 1980 and December 2013 and identified 69 studies from Africa (n=9), North America and Brazil (n=6), Asia (n=36), Europe (n=16), and Oceania (n=2). In all the studies men outnumbered women, the ratio usually being more than 2:1. In American, African, and Asian studies road traffic crashes were the predominant cause. In European studies the aetiology varied, with assaults and road traffic crashes being the most important factors. In Oceania assaults were the most important. A comparison of the incidence of maxillofacial trauma of different countries together with a knowledge of different laws (seat belts for drivers, helmets for motocyclists, speed limits, and protection worn during sports and at work) is crucial to allow for improvement in several countries. To our knowledge this paper is the first attempt to study and compare the aetiologies of maxillofacial trauma. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Maxillofacial trauma; Maxillofacial; Facial; Fracture; Etiology; Cause; Mechanism; Epidemiology

Introduction Maxillofacial injuries are a serious public health and economic problem, as their treatment, and time spent in hospital and off work, is expensive. They are also often associated with severe morbidity, disfigurement, and psychological problems.1–69 Their epidemiology may vary widely from country to country (and even within the same country), and it is dependent on several factors, including culture, socioeconomic background, and population density.9,28,30,33,38,46

∗ Corresponding author. Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. E-mail address: [email protected] (P. Boffano).

First, the populations in urban and rural environments differ in density and infrastructure. The incidence of road traffic crashes may depend on: increases in the volume of traffic, a substantial rural to urban drift of the productive segment of the population, deteriorating infrastructure such as roads, road building programmes, widespread use of second-hand vehicles, young people driving illegally, young children travelling as front seat passengers without restraint, driving under the influence of alcohol, and non-compliance with legislation about seatbelts and crash helmets.6,12,25–27,30,38 However, enforcement of legislation about seat belts and crash helmets, measures for speed control, restrictions about driving under the influence of alcohol, the use of surveillance cameras in the streets, the development of subways, and the control of heavy wagons, can reduce the number of road traffic crashes.6,12,25–27,30,38

http://dx.doi.org/10.1016/j.bjoms.2014.08.007 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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Since the implementation of programmes to reduce road traffic crashes and apply restraints in some countries, the ease of acquiring weapons and increasingly aggressive behaviour in urban centres have led to a rise in the number of assaults, and replaced road crashes as the leading cause of maxillofacial injuries.12 The change in assault weapons, with fists or heavy articles being replaced by knives or other sharp weapons, may affect the number of facial injuries.25 The discrepancy in assault-related facial injury may also depend on differences in social customs and alcohol intake, and some specific religious practices or social habits may limit or forbid the drinking of alcohol.20 Excessive consumption is strongly associated with assaults, as it impairs judgement, encourages aggression, and often leads to interpersonal violence.9 The strictness of laws governing the sale and consumption of alcohol in some countries may have effectively prevented alcohol-related injuries in some countries.9 Finally, it is important to remember that turbulent political transition in a country may generate a certain insubordination by part of the population and increase the rate of assaults.60 Social and cultural factors are crucial in sports injuries, as the popularity of contact sports such as rugby or boxing can dramatically increase the rate of sport-related maxillofacial injuries.38 The rate of accidents at work also differs from country to country and even within the same country, as specific categories of worker are at higher risk of facial injury (such as construction and forestry workers).38 In these cases, enforcement of work protection legislation is fundamental. In some countries men usually work outdoors and women are mainly confined to the house or work as teachers, nurses, and doctors, and only few of them drive cars.26,38 This has resulted in an increase in the male:female ratio in several countries.26,38 In countries where women participate directly in social activities and consequently are more susceptible to traffic crashes and urban violence, the ratio of men:women with maxillofacial injuries can be much lower.12 The more active lifestyles, increased life expectancy, and a general increase in the number of elderly people also play a part in the increase in the age of people with such injuries.25 Thorough knowledge and understanding of the aetiology and epidemiology of facial injuries is fundamental for the development of health services, the training of maxillofacial surgeons, and the adoption of new methods of preventing injuries. The aim of this paper, therefore, was to review and discuss papers that were published during the past 30 years about the distribution and aetiology of facial injuries throughout the world.

Material and methods We systematically reviewed all papers that were published in English between January 1980 and December 2013 using MEDLINE and the MeSH term “facial fractures” together

with the terms “review”, “‘epidemiology”, and “aetiology”. Twelve papers in other languages were excluded. Papers that presented complete data about the sex distribution and aetiology of the groups studied were identified and included. Those that gave epidemiological data only about specific groups or specific conditions (such as children, old people, and military exercises) were excluded, as well as those that recorded only specific maxillofacial trauma such as injuries to the mandible alone. Data were collected on sex distribution and aetiology, and summarised in tables according to continents. Papers were classified according to the size of the sample, for which they were rated A (n=1000 or more), B (n=200999), or C (n=<200), and the design, for which they were rated 1 (prospective) or 2 (retrospective).

Results A total of 69 studies were identified from Africa (n=9), from North America and Brazil (n=6), from Asia (n=36), from Europe (n=16), and from Oceania (n=2) (Tables 1–5). Only 6 paperss1,11,12,40,56,59 were rated A1 according to our classification. The others were classified as A2 (n=18), B1 (n=4), B2 (n=29), C1 (n=5), and C2 (n=7). In all studies men outnumbered women, the male:female ratio usually being more than 2:1. In African studies most showed a male:female ratio of 4:1 or more (Table 1), but the trend during the last 30 years has shown a slight decrease with an adjustment towards 4/5:1. With few exceptions African studies showed that in most cases road traffic crashes have remained the most important aetiological factor, with a progressive reduction during the last 20 years. Assault was the second most common cause of maxillofacial injury in several papers, whereas falls and sport accidents were more sporadic. In North America and Brazil (Table 2), male:female ratios were between 2:1 and 4.3:1 and tended to stabilise during the last 3 decades. Road traffic crashes were the most important cause in almost all studies and the number remained stable, followed by assaults, the incidence of which progressively increased. Papers from Asia included most of the epidemiological studies (Table 3). Male:female ratios were extremely variable, and ranged from 2.1:1 to 20:1, but no solid trend was apparent across the last 30 years, partly because of the great social and economic differences among the countries. However, there was a predominance of road traffic crashes in nearly all studies, with percentages of over 45% – 50% even during recent years. Only two studies presented assaults as the most important aetiological factor.22,29 Falls remained a common cause in all countries, with percentages often higher than 20%. In Europe the male:female ratios ranged between 1.8:1 and 6.6:1 and remained stable across the last 3 decades (Table 4).

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Table 1 Aetiology of maxillofacial fractures in Africa. First author

Adekeye1 Abiose2 Khan3 Ugboko4 Olasoji5 Adebayo6 Schaftenaar7 Hassan8 Chalya9 ∗

Year

1980 1986 1988 1998 2002 2003 2009 2010 2011

Time period

1973 – 1978 1982 – 1984 1985 – 1986 1982 – 1995 1996 – 1999 1991 – 2000 2001 – 2007 2008 – 2009

Country

Nigeria Nigeria Zimbabwe Nigeria Nigeria Nigeria Tanzania Egypt Tanzania

No of patients

1447 104 311 442 206 443 532 255 154

M:F ratio 16.9:1 72.7 5.5:1 4.3:1 4.1:1 2.19:1 4.7:1 4.3:1 5.5:1 2.7:1

Causes (%) Road crashes

Assault

Falls

Sport

Other

80.8 14.8 71.9 36 56 42.3 54 57.1

12.7 13.5 81.6 8.4 48 13 39.1 9.4 16.2

7.9 1.9 10.9 9 24 6.6 14.3

1.3 1.9 3.6 3.2 4 5 4.9 2.6

5.3 1.9 5.6 3 3 7.1 36.5* 9.7

Activities of daily life and accidents + other cause.

The aetiology was extremely variable, in that in several studies road traffic crashes were the most common cause, whereas in 5 assaults were the most common cause. There was also a progressively increasing trend in the incidence of falls, whereas sport accidents were the cause in more than 10% of facial trauma overall. Finally, in Oceania the male:female ratio was 4:1 (Table 5), with assaults as the most important cause of maxillofacial injuries, followed by road crashes.

Discussion Knowledge about the epidemiology of maxillofacial trauma is fundamental for every maxillofacial surgeon and for all national health systems, and thanks to a thorough knowledge of the mechanisms of injuries, preventive measures can be introduced. The male:female ratio is an important variable. In all studies men outnumbered women with the male:female ratio usually above 2:1. Several studies did not give it in the different aetiological categories, but the information would be valuable. On the whole, lower male:female ratios were quoted in papers from Europe and North America and Brazil, whereas papers from Asia and Africa reported the highest ratios. Road traffic crashes remain the most important cause of maxillofacial trauma all over the world, although there was a progressively decreasing trend, particularly in North America and Brazil, and Europe. In these continents, assaults and falls have become more important, probably as a result of

more severe traffic laws and the consequent reduction in road traffic crashes in general. The general ageing of the European population may also play a part in the increase of falls. Sport accidents remain relatively rare all over the world with the exception of Europe, where they cause more than 10% of facial trauma. We found a wide variation in aetiology between studies from the same country, even during the same period of time. Of course this can be explained by the different social groups that used the particular hospital or trauma centre being studied. A hospital may be a tertiary centre for a mostly rural or urban population, which would reflect a different pattern of work. Rates of criminal behaviour may differ from town to town, which would give a different role to assault as an aetiological factor for maxillofacial injuries. In some countries (such as North America) maxillofacial fractures are treated by multiple specialty services and without a uniform system of trauma centres, so there may be bias in the reports of aetiologies. It is almost impossible therefore to compare data from groups of injured patients statistically, even within the same country. However, there may be a general pattern of aetiological factors shown by assessment of this analysis and of eventual future prospective studies, keeping in mind that laws, drinking habits, standards of roads, types of work, and other conditions can vary even in the same country. For this reason this study has several biases and limitations, but to our knowledge it is the first complete review of the epidemiology of maxillofacial trauma. The most important biases include the difference in classifications of some causes of injury, such as accidents at work. This category

Table 2 Aetiology of maxillofacial fractures in North America and Brazil. First author

Year

Time period

Country

No of patients

M:Fratio

Vetter10 Hogg11 Brasileiro12 Erdmann13 De Souza Maliska14 Smith e15

1991 2000 2006 2008 2009 2012

1986 – 1988 1992 – 1997 1999 – 2004 2003 – 2005 2002 – 2006 2008 – 2009

USA Canada Brazil USA Brazil USA

311 2969 1024 437 132 154

2.8:1 3:1 4:1 2.5:1 4.3:1 2:1

Causes (%) Road crashes

Assault

Falls

Sport

Other

40 70 45 32 48.4 47

37 8 23 36 36.4 -

12 12 18 18 9.8 25

9 8 11 -

2 11 6 3 5.4 28

904

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Table 3 Aetiology of maxillofacial fractures in Asia. First author

Nair16 Karyouti17 Sawhney18 Tanaka19 Bataineh20 Iida21 Aksoy22 Klenk23 Motamedi24 Ansari25 Al Ahmed26 Erol27 Cheema28 Kadkhodaie29 Al-Khateeb30 Subhashraj31 Sasaki32 Abbas33 Ozkaya34 Lee35 Venugopal36 Hashim37 Gandhi38 Mesgarzadeh39 Zandi40 Kamath41 Naveen Shankar42 Kapoor43 Singh44 Kar and Mahavoi45 Abdullah et al46 Almasri47 Bali et al48 Jin et al49 Mijiti et al50 Zhou et al51

Year

1986 1987 1988 1994 1998 2001 2002 2003 2003 2004 2004 2004 2006 2006 2007 2007 2009 2009 2009 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2012 2013 2013 2013 2013 2013 2013

Time period

1982 – 1983 1981 – 1983 1982 – 1983 1977 – 1989 1992 – 1997 1981 – 1996 1994 – 2001 1998 – 2001 1996 – 2001 1987 – 2001 1999 – 2002 1978 – 2002 2001 – 2002 2001 – 2004 1995 – 2003 1999 – 2005 2000 – 2004 2001 – 2007 2000 – 2005 2003 – 2007 2004 – 2008 2007 – 2008 2006 – 2009 2001 – 2006 2007 – 2009 2004 – 2009 2000 – 2005 2008 – 2009 2006 – 2011 2004 – 2009 2007 – 2011 2010 – 2011 2003 – 2010 2008 2006 – 2010 2000 – 2009

Country

No of patients

India Jordan India Japan Jordan Japan Turkey United Arab Emirates Iran Iran United Arab Emirates Turkey Pakistan Iran United Arab Emirates India Japan Pakistan Turkey Republic of Korea India Malaysia India Iran Iran India India India India India Saudi Arabia Saudi Arabia India China China China

313 131 262 695 563 1502 553 144 237 2268 230 2901 702 7200 288 2748 674 952 216 318 361 194 718 170 895 111 2027 1000 1038 503 200 101 740 627 1350 1131

M:Fratio

13.9:1 4:1 4:1 3.2:1 3:1 2.8:1 4.8:1 5:1 8.1:1 3.8:1 11.8:1 3.4:1 5.3:1 12:1 7:1 3.7:1 3.6:1 2.1:1 3.1:1 3.2:1 20:1 4.5:1 6.6:1 3.8:1 3.4:1 10:1 7:1 5.8:1 9:1 7.25:1 6.1:1 4.2:1 4.6:1 4.9:1 3.5:1

Causes (%) Road crashes

Assault

Falls

Sport

Other

40.3 61.1 50 38.4 55 52 90 59 54 60 75 38 54 91 56 85 31 38.9 67.1 17 87 61.8 72 40 43.4 74.7 64.1 40 97 80.3 61 89.1 72 54.4 47.5 52.6

24.6 38.9 13 15.5 17 15.5 2.7 4 9.7 10 8 10 8 2.9 9 3 23 10.7 19.4 40.9 6 16 13.5 18.4 15.8 8.6 54 0.4 13.9 11.5 7.9 5 13.9 17.6 14.1

24 18 24.8 20 16.6 4.9 21.5 20.3 19 12 36.7 19 5.5 20 7 29 27 12.5 25 4 19.6 9.3 20.5 25.8 4.2 24 3 2 3 20 0 16 17.2 22 22.7

7 15.5 6 9.7 0.4 5 6.3 1 2.6 1.1 0.5 0.6 3 2 14 10.9 0.9 11.9 3 0.8 9.5 6.9 1 1 1 5.5 3 2 1.3 3 1.8

11.1 12 5.8 2 6.2 2 11.5 9.7 11 2.4 14 18.5 1 12 2 3 12.5 0.1 5 18.6 2 16.5 2.3 5.3 2.3 2 0.6 1.8 2 0 5 13.2 10 8.9

Road crashes

Assault

Falls

Sport

Other

34.8 58 23 57 48 24.7 14 50.5 12 15.5 27 11 35.2 50.8 68.8 4 42

27.1 8 30.5 9 17.5 40.1 48 13.4 12 61 20.5 14 22.3 26.3 7.3 72 16

20 15 12.4 12.5 7.8 38 17.4 13.8 4.3 18 21

12.8 4 16.3 4 18 16 7 15.3 31 1.5 11 35 8.3 3 17.1 5 12

25.3 30 30.2 10 16.3 19.2 16 8.4 45* 9.5 43.7 2 14.8 3 2.4 1 9

Table 4 Aetiology of maxillofacial fractures in Europe. First author

Afzelius52 Zachariades53 Hill54 Zachariades55 Timoney56 Timoney56 Torgersen57 Van Beek58 Gassner59 Bakardjiev60 Pombo61 Walker e62 Van den Bergh63 Kostakis64 Kyrgidis65 Rashid66 Van Hout67 ∗

Year

1980 1983 1984 1990 1990 1990 1992 1999 2003 2007 2010 2012 2012 2012 2013 2013 2013

Time period

1969 – 1976 1970 – 1980 1979 – 1983 1960 – 1984 1985 – 1986 1985 – 1986 1989 – 1991 1975 – 1987 1991 – 2000 1994 – 2003 2001 – 2008 2009 2000 – 2010 2005 – 2009 1998 – 2008 2005 – 2010 2005 – 2010

Country

Sweden Greece UK Greece France UK Norway The Netherlands Austria Bulgaria Spain Ireland The Netherlands Greece Greece UK The Netherlands

Activities of daily life and accidents + other cause.

No of patients

368 1791 827 3908 1146 506 169 1324 9543 1706 643 82 579 727 1239 1261 394

M:Fratio

3.8:1 3.6:1 2.6:1 3:1 3:1 3:1 3.7:1 2.8:1 2:1 4.6:1 4.9:1 1.8:1 2.4:1 5.7:1 4.4:1 6.6:1 3:1

Causes (%)

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905

Table 5 Aetiology of maxillofacial fractures in Oceania. First author

68

Buchanan Cabalag 69

Year

2005 2013

Time period

1989 – 2000 2009 – 2011

Country

New Zealand Australia

No of patients

2527 980

(which was rarely considered as a specific cause) was included under “other causes”. The classification of bicycle accidents is still a problem, as they have been considered among falls, road traffic crashes, or sport. As we have said before, bicycle accidents and accidents at work should be considered as specific aetiological factors. A classification system for future reporting of injuries could be proposed, including different categories such as assaults, road traffic crashes, falls, accidents at work, sports accidents, bicycle accidents, and other causes. Of course, a more precise subclassification of causative mechanisms could be adopted too, including type of sport, type of work, and type of road traffic crash. We conclude that road traffic crashes remain the most important cause of maxillofacial trauma all over the world, with the exception of North America and Europe, where assaults and falls have become important. Sports accidents remain quite rare all over the world, whereas in Europe they constitute more than 10% of facial trauma. A multicentre, prospective epidemiological study is needed to investigate this complex subject thoroughly.

Conflict of interest We have no conflicts of interest. Ethics statement/confirmation of patients’ permission Not required.

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11 21

18 15

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