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European Maxillofacial Trauma (EURMAT) project: A multicentre and prospective study
Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 62e70
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European Maxillofacial Trauma (EURMAT) project: A multicentre and prospective study Paolo Boffano a, *, Fabio Roccia b, Emanuele Zavattero b, Emil Dediol c, Vedran Uglesi c c, c e, Milan Petrovi c e, Ziga Kova ci c d, Ales Vesnaver d, Vitomir S. Konstantinovi f f f f Jonny Stephens , Amar Kanzaria , Nabeel Bhatti , Simon Holmes , Petia F. Pechalova g, Angel G. Bakardjiev g, Vladislav A. Malanchuk h, Andrey V. Kopchak h, Pål Galteland i, Even Mjøen i, Per Skjelbred i, Carine Koudougou j, Guillaume Mouallem j, Pierre Corre j, Sigbjørn Løes k, Njål Lekven k, Sean Laverick l, Peter Gordon l, Tiia Tamme m, Stephanie Akermann m, K. Hakki Karagozoglu a, Sofie C. Kommers a, Tymour Forouzanfar a a Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands b Department of Maxillofacial Surgery, University of Turin, Turin, Italy c Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia d Maxillofacial Department, UKC Ljubljana, Slovenia e Clinic of Maxillofacial Surgery, School of Dentistry, University of Belgrade, Serbia f Department of Oral and Maxillofacial Surgery, Royal London Hospital, Barts Health NHS, London, UK g Department of Maxillo-facial Surgery, Medical University, Plovdiv, Bulgaria h Department for Oral and Maxillo-facial Surgery, Bogomolets National Medical University, Kiev, Ukraine i Department of Maxillofacial Surgery, Oslo University Hospital, Oslo, Norway j Service de Stomatologie et Chirurgie Maxillo-faciale, Chu de Nantes, France k Department of Maxillofacial Surgery, University of Bergen, Bergen, Norway l Department of Oral and Maxillofacial Surgery, NHS Tayside, University of Dundee, Dundee, UK m Department of Maxillofacial Surgery, Stomatology Clinic, Tartu University, Tartu, Estonia
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Article history: Paper received 1 July 2014 Accepted 15 October 2014 Available online 22 October 2014
The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery over one year. The following data were recorded: gender, age, aetiology, site of facial fractures, facial injury severity score, timing of intervention, length of hospital stay. Data for a total of 3396 patients (2655 males and 741 females) with 4155 fractures were recorded. The mean age differed from country to country, ranging between 29.9 and 43.9 years. Overall, the most frequent cause of injury was assault, which accounted for the injuries of 1309 patients; assaults and falls alternated as the most important aetiological factor in the various centres. The most frequently observed fracture involved the mandible with 1743 fractures, followed by orbital-zygomatic-maxillary (OZM) fractures. Condylar fractures were the most commonly observed mandibular fracture. The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe, with trauma cases caused by assaults and falls now outnumbering those due to road traffic accidents. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. Men are still the most frequent victims of maxillofacial injuries. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Aetiology Assaults Cause Epidemiology Facial fracture Mandible
* 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). http://dx.doi.org/10.1016/j.jcms.2014.10.011 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
P. Boffano et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 62e70
1. Introduction The epidemiology of maxillofacial fractures is extremely variable, depending on several factors such as the geographical area, cultural and lifestyle differences, and socioeconomic trends (Gandhi et al., 2011; Kostakis et al., 2012; Naveen Shankar et al., 2012; Lee, 2012; van Hout et al., 2013). Common causes of facial fractures are road traffic accidents (RTA), assaults, falls, and sports and work injuries (Naveen Shankar et al., 2012). RTAs have often been described as the primary cause of facial fractures (Al-Khateeb and Abdullah, 2007; Chrcanovic et al., 2012; Naveen Shankar et al., 2012), although assaults and interpersonal violence have been found to be the most important aetiological factor by other authors (Mijiti et al., 2014). In recent years, there has been a decreasing trend in RTA-related facial trauma in several developed countries due to changes in road safety legislation. Following the reduction of maxillofacial trauma caused by traffic accidents, interpersonal violence has become increasingly important as an aetiological factor (Kraft et al., 2012; Kostakis et al., 2012). Facial trauma is a huge public health problem because of the significant negative impact on an individual's overall physical and psychological health and also because of the associated socioeconomic consequences that cannot be ignored. The cost of treatment and admission to hospital, the use of hospital resources, and finally the macroeconomic loss of revenue can be significant after such injuries (Lee, 2012; van Hout et al., 2013; Mijiti et al., 2014). Epidemiological analysis of maxillofacial injuries is important to identify the trauma burden and to help develop more efficient ways to plan resource allocation and to deliver care and preventive measures (Lee, 2012; van Hout et al., 2013; Mijiti et al., 2014). The knowledge of the cause, frequency, and severity of maxillofacial fractures plays an important role in establishing effective treatment and prevention measures (Kostakis et al., 2012). However, in the literature, most epidemiological studies on this important topic have been retrospective or based at a single centre. In particular, the lack of a multicentre prospective study on maxillofacial trauma epidemiology in Europe has been observed. Therefore, several European centres that had already shown research experience in maxillofacial trauma decided to collaborate on a prospective multicentre study on facial fracture epidemiology in Europe (Skjelbred, 1992; Uglesi c et al., 1993; Tamme et al., 2004; Vesnaver et al., 2005; Holmes et al., 2006; Bakardjiev and Pechalova, 2007; Galteland and Skjelbred, 2007; Malanchuk and Kopchak, 2007; Key et al., 2008; Laverick et al., 2008; Vesnaver, 2008; Gerbino et al., 2009a,b; Laverick et al., 2009; Konstantinovic et al., 2010; Brajdi c et al., 2011; Holmes, 2011; Lekven et al., 2011; van den Bergh et al., 2011, 2012a,b; Ahmad et al., 2012; Al-Qamachi et al., 2012; Dediol, 2012; Kokemueller et al., 2012; Vesnaver et al., 2012; Boffano et al., 2013a,b, Boffano et al., 2014a,b,c; Corre et al., 2013; McAllister et al., 2013). The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery. The results of this collaboration in a multicentre prospective study on maxillofacial trauma epidemiology over a one-year period are presented here. 2. Material and methods The present study was conducted at several European departments of oral and maxillofacial surgery: the Department of Oral and Maxillofacial Surgery/Pathology at the VU University Medical Center and Academic Centre for Dentistry Amsterdam (Amsterdam, The Netherlands); the Department of Maxillofacial Surgery at the
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University of Turin (Turin, Italy); the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia); the Maxillofacial department at the UKC Ljubljana, (Ljubljana, Slovenia); the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia); the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health NHS (London, UK); the Department of Maxillofacial Surgery at the Medical University (Plovdiv, Bulgaria); the Department for Oral and Maxillofacial Surgery at the Bogomolets National Medical University (Kiev, Ukraine); the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway); the Service de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France); the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway); the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK); and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computer-assisted database that allowed the prospective and continuous recording of all patients hospitalized with maxillofacial fractures in the involved maxillofacial surgical units across Europe, between Monday 31 December 2012 and Sunday 29 December 2013. The following data were recorded for each patient: gender, age, aetiology, aetiology subtype, site of facial fractures, facial injury severity score (FISS) (Bagheri et al., 2006), date of injury, timing of intervention, and length of hospital stay. The following categories of cause of injury were considered: falls, road traffic accidents (RTA), assaults, sport injuries, work injuries, and other causes. Sport injuries were analysed and divided according to the type of sport. Road traffic accidents were classified according to the mechanism of injury (car accident, motorbike accident, pedestrian, bicycle accident, unknown/other). Work injuries were divided according to the type of work: construction workers, factory workers, farm and forestry workers, office workers, other. Fractures were determined from computed tomography scans at admission to hospital and classified as fractures of the mandible, orbital-zygomatic-maxillary complex (OZM), orbit, nose, Le Fort, frontal sinus, and naso-orbital-ethmoid (NOE) fracture. Orbital fractures were subclassified according to the involved walls and Le Fort fractures were divided according to Le Fort types I, II, and III. Frontal sinus fractures were divided according to the involvement of the anterior and/or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extra-articular condyle, intra-articular condyle. Data regarding the timing of intervention (within 24 h from hospitalization, between 24 and 72 h, after 72 h from hospitalization) were collected. Finally, the dates of injury were grouped and analysed according to the month. Patient characteristics were analysed using descriptive statistics.
3. Results Between Monday 31 December 2012 to Sunday 29 December 2013, 3396 patients with a total of 4155 fractures presented to the centres participating in the EURMAT project. Of the 3396 patients with maxillofacial fractures admitted within the study period, 2655 (78.2%) were male and 741 (21.8%) were female, with a male to female ratio of 3.6:1. In the different centres and countries the male to female ratio varied widely, with the highest value encountered in the Kiev centre (Ukraine) study population (9.4:1) and the lowest value that was observed in Amsterdam (The Netherlands) with an M:F ratio of 2.2:1 (Fig. 1).
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Fig. 1. Percentages of males and females in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
The observed mean age was different from country to country, ranging between 29.9 years in the Dundee centre (Scotland, UK) and 43.9 years in Ljubljana (Slovenia). However, most centres presented a mean age that was included in the decade 30e39 years, with the following values: 34.7 in Plovdiv (Bulgaria), 33.6 in Tartu (Estonia), 32.7 in Nantes (France), 38 in Oslo (Norway), 31.9 in Bergen (Norway), 35.4 in Belgrade (Serbia), 32.8 in Kiev (Ukraine), and 34 in London (England, UK) (Fig. 2). In almost all centres the mean age of females was higher or remarkably higher than the males (Table 1). The most important difference was observed in Zagreb (Croatia) where the mean age was 55.8 in females and 38.9 in males. Instead, in Bergen (Norway) an inversion of values was observed with a mean age of 31.2 in women and 32.1 in men. As for aetiology, the most frequent cause of injury was assault with 1309 patients, followed by falls (1050 patients), sport accidents (385 patients), RTAs (375 patients), work accidents (117 patients), and other causes (160 patients) (Fig. 3). The aetiology of maxillofacial injuries changed from centre to centre, with assaults and falls alternating as the most important aetiological factor: assaults were the predominant cause in Plovdiv (Bulgaria), Tartu (Estonia), Oslo (Norway), Belgrad (Serbia), Kiev (Ukraine), London (England, UK), and Dundee (Scotland, UK); whereas falls were the most important aetiological factor in Turin (Italy), Nantes (France), Zagreb (Croatia), Bergen (Norway), Amsterdam (The Netherlands), and Ljubljana (Slovenia) (Fig. 4). In all centres with a mean age higher than 40 years (Turin, Zagreb, Amsterdam, and Ljubljana), falls were the most important cause of maxillofacial trauma. As for RTAs, car accidents were responsible for the trauma in 177 out of the 375 cases (42.7%). Other RTA aetiological factors were
motorbike accidents (91 cases, 24.3%), bicycle accidents (49 cases, 13.1%), pedestrian versus car accidents (33 patients, 8.8%) and other/unknown causes (25 patients, 6.6%). Small variations were observed from country to country, with the exception of Plovdiv and Tartu (where car accidents were responsible for more than 85% of RTAs). In the group of patients with sport-related accidents, soccer was most frequently responsible for maxillofacial injuries (141 patients, 36.6%), followed by rugby (62 cases, 16.1%), skiing (37 patients, 9.6%), basketball (19 cases, 4.9%), hockey (15 patients, 3.9%), and combat sports (9 patients, 2.3%); a total of 102 cases were from unspecified or other sports. The most frequently involved work category in work-related facial fractures was farm and forestry workers. This group of workers presented 35 cases out of 117 (29.9%). Other involved categories were construction workers (32 patients, 27.3%), factory workers (24 cases, 20.5%), office workers (6 patients, 5.2%), and others (20 patients, 17.1%). The percentages of work-related maxillofacial injuries are summarized in Fig. 5. The most frequently observed fracture involved the mandible with 1743 fractures, followed by OZM fractures (1010 fractures), orbital fractures (656), nose fractures (395), Le Fort fractures (195), frontal sinus fractures (110), and NOE fractures (46) (Fig. 6). A noticeable variability was observed in fracture types from country to country (Fig. 7). As for the mandible, 592 condylar fractures were observed, representing the most commonly observed mandibular fracture accounting for the 34% (extracapsular condyle, 26%; intracapsular condyle, 8%). These were followed by body fractures, angle fractures, fractures of the symphyseal region, dentoalveolar fractures,
Fig. 2. Mean age (years) in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
P. Boffano et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 62e70 Table 1 The mean age of female and male patients in the different study centre populations. Centre
Female mean age (years)
Male mean age (years)
Turin, Italy Plovdiv, Bulgaria Tartu, Estonia Nantes, France Zagreb, Croatia Oslo, Norway Bergen, Norway Amsterdam, The Netherlands Ljubljana, Slovenia Belgrad, Serbia Kiev, Ukraine London, England, UK Dundee, Scotland, UK
44.8 36.9 36.1 36.6 55.8 41.8 31.2 43.7 51.5 47.4 37.2 34.2 31.9
39.1 34.2 33.1 31.3 38.9 36.8 32.1 38.9 41.3 33.4 32.4 33.8 29.7
fractures of the ramus, and coronoid fractures in decreasing numbers (Fig. 8). The FISS mean score in the study populations ranged between 1.6 (Nantes) and 3 (Bergen), with a substantial uniformity between all centres. However, the mean hospital stay presented wider differences: the minimum values were observed in Dundee (2 days) and Nantes (2.1 days), whereas the maximum values were encountered in Kiev (10.6 days), Turin (4.8 days), and Zagreb (4.8 days) (Fig. 9). As for timing of intervention, in the whole European population 44.6% of fractures were treated beyond 72 h from injury; 37.1% of patients underwent treatment within 24 h; and in the remaining 28.3% of cases treatment was performed within 72 h (but after 24 h) from injury. In this specific analysis, the widest variation was observed from centre to centre, as shown in Fig. 10. Finally, the analysis of dates of injury allowed us to calculate the monthly distribution of maxillofacial trauma (Fig. 11): a uniform distribution across all months is noted, with slightly higher values during the summer months. 4. Discussion The incidence, aetiology, clinical presentation, and characteristics of maxillofacial fractures are influenced by sociodemographic, economic, and cultural factors of the population studied (Kostakis et al., 2012; Naveen Shankar et al., 2012; Mijiti et al., 2014). This prospective multicentre study was designed to obtain reliable epidemiological data about maxillofacial trauma in Europe. In fact, the collaboration of maxillofacial surgery units across Europe in gathering uniform data allowed a decrease in the bias of patient
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selection and surgical techniques; increased the study population; and gave information about the epidemiology of maxillofacial trauma in different regions. The prevalence of men involved in maxillofacial trauma is strongly supported by previous literature, with male to female ratios ranging between 2:1 to 8:1 (Gandhi et al., 2011; Allareddy et al., 2011; Kostakis et al., 2012; Kraft et al., 2012; Lee, 2012; Mijiti et al., 2014). The present study results also suggest that a larger proportion of patients with maxillofacial fractures are male. In fact, in our study, of the 3396 patients with maxillofacial fractures admitted within the study period, 2655 (78.2%) were male and 741 (21.8%) were female, with a male to female ratio of 3.6:1. This can be explained by the fact that men would be more actively involved in social activities, thus being more susceptible to traffic accidents, interpersonal violence, and work- and sport-related injuries (Kostakis et al., 2012). Although the recent literature shows a trend towards a more equal male to female ratio in the last three decades (Gandhi et al., 2011; Lee, 2012), men still outnumbered women in our study population. However, in the different centres and countries the value of the male to female ratio varied widely, with the maximum value encountered in Kiev (9.4:1) and the minimum value in Amsterdam with an M:F ratio of 2.2:1. In particular, Plovdiv, Tartu, Zagreb, Belgrad, Kiev, and Dundee presented percentages of men above 80%, whereas Turin, Nantes, Oslo, Bergen, Amsterdam, Ljubljana, and London showed percentages of men ranging between 65% and 80% (Fig. 1). Therefore, a tendency to higher male to female ratios could be observed in Eastern Europe, whereas lower male to female ratios were usually found in Western European countries. The gender ratio in facial trauma also changes depending on the cause (Lee, 2012; Mijiti et al., 2014). For example, in almost all the EURMAT centres that presented a percentage of assault related maxillofacial fractures of 40% or higher, men represented more than 80% of the single centre population (Plovdiv, Tartu, Belgrad, Kiev, and Dundee) (Figs. 1 and 4). In the literature, maxillofacial fractures occur most frequently in people aged 20e30 years (Al Ahmed et al., 2004; Ansari, 2004; Brasileiro and Passeri, 2006; Al-Khateeb and Abdullah, 2007; Gandhi et al., 2011; Kraft et al., 2012; Lee, 2012; Mijiti et al., 2014). In the EURMAT collaboration, most centres presented a mean age that was included in the decade from 30 to 39 years (Fig. 2). Furthermore, in almost all centres the mean age of females was higher or remarkably higher than males (Table 1). These results could be due to an increase in life expectancy (especially in women) and the
Fig. 3. Percentages of causes of maxillofacial trauma in the whole EURMAT study population.
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Fig. 4. Percentages of causes of maxillofacial trauma in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
ageing of European people, together with an increasingly active elderly population (Gandhi et al., 2011; Lee, 2012). The aetiology of facial trauma directly affects the incidence, clinical presentation, and treatment modalities of the facial fractures (Mijiti et al., 2014). Therefore, it is a crucial aspect to investigate during epidemiological studies such as ours. In the maxillofacial trauma literature, RTAs, assaults and falls are the leading causes, with a wide range of relative frequencies, depending on the socioeconomic, cultural and environmental factors of the country (Cabalag et al., 2014). Of course, a changing trend in both developing and developed countries could be found in recent articles. In fact, in the developed nations, the major cause of the injuries seems to have become interpersonal violence whereas in developing countries RTAs are still the most important aetiological factor (Al-Khateeb and Abdullah, 2007; Gandhi et al., 2011; Chrcanovic et al., 2012). In the EURMAT collaboration, the most frequent cause of injury was assault, with 1309 patients, followed by falls (1050 patients), sport accidents (385 patients), RTAs (375 patients), work accidents (117 cases), and other causes (160 patients) (Fig. 3). However, as aforementioned, a variation could be observed between centres, but assaults and falls were always the two most important causes (Fig. 4). It was curious to observe that in all centres with a mean age higher than 40 years (Turin, Zagreb, Amsterdam, and Ljubljana), falls were the most important cause of maxillofacial trauma. This strongly supports the fact that falls would be more and more associated with an elderly population. Therefore, the increasing age of the European population could be responsible for the progressive increase of fall-related maxillofacial injuries; this is likely to continue.
It is also be interesting to notice that assaults were the most frequently observed cause in almost all the centres where more than 80% of the injured patients are male (Plovdiv, Tartu, Belgrad, Kiev, and Dundee), thus supporting the association between men and assaults leading to maxillofacial injury. Surprisingly, in the EURMAT population, RTAs were even outnumbered by sport accidents, representing just the fourth cause of maxillofacial trauma as a whole. In particular, car accidents were still responsible for most RTAs (47.2%), followed by motorbike accidents, bicycle accidents, and pedestrian versus car accidents. In sport accidents, football/soccer was the most frequent cause for maxillofacial injuries (36.6%), followed by rugby, skiing, and basketball. The extremely low percentages of RTAs and work accidents could be associated with recent strict road traffic and work safety laws in most European countries. In fact, the implementation of safety norms like mandatory seat belts, air bags, helmet wearing for motorized two-wheelers and speed limits, in addition to strict policies against drinking and driving seem to have contributed to a dramatic decrease in road traffic related maxillofacial trauma. Work accidents could also have been reduced by more efficient safety laws and regulations. The most frequently observed fracture involved the mandible with 1743 fractures (42%), followed by OZM fractures (24%), orbital fractures (16%), nose fractures (9%), Le Fort fractures (5%), frontal sinus fractures (3%), and NOE fractures (1%) (Fig. 6). Previous studies have shown that the mandible is the most common site for maxillofacial fracture, often followed by zygoma as in our population (Ansari, 2004; Al-Khateeb and Abdullah, 2007; Allareddy et al., 2011; Mijiti et al., 2014).
Fig. 5. Percentages of work-related maxillofacial injuries in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
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Fig. 6. Percentages of the different types of maxillofacial fractures in the whole EURMAT study population.
Fig. 7. Percentages of maxillofacial fractures in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Of course, our results in fracture site distribution suffer from an important limitation that characterizes several maxillofacial departments: nose fractures are often treated by ENT departments, thus possibly changing the real epidemiology and percentages of fractures of the facial bones.
As for the mandible, condylar fractures represented the most commonly observed mandibular fracture accounting for the 34%. These fractures were followed by body fractures, angle fractures, fractures of the symphyseal region, dentoalveolar fractures, fractures of the ramus, and coronoid fractures in decreasing numbers.
Fig. 8. Percentages of mandibular fractures in the whole EURMAT study population.
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Fig. 9. FISS and hospital stay values in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Fig. 10. Percentages of timing of intervention in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Our finding was consistent with previous studies (Gandhi et al., 2011). In particular, the high incidence of condylar fracture could be related to the high percentage of fall-related injuries in the EURMAT study population. The present study did not thoroughly examine the different types of treatment for maxillofacial fractures that would strongly
influence the length of hospital stay and the recovery. However, the analysis of FISS mean scores together with length of hospital stays in the various EURMAT centres still gave interesting results. In fact, whereas FISS mean scores showed a substantial uniformity between all centres in the study populations (ranging between 1.6 and 3), mean hospital stays presented wider differences. In contrast
Fig. 11. Percentage of injuries occurring each month in the EURMAT study population.
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with the extremely low values observed in Dundee (2 days) and Nantes (2.1 days), much higher values were found in Kiev (10.6 days), Turin (4.8 days), and Zagreb (4.8 days) (Fig. 9). In addition to the chosen treatment (open or closed), these different values could find an explanation in the differences and peculiarities of the health care systems, the referral of trauma patients directly to the trauma centre, and the postoperative management of maxillofacial trauma patients. As for timing of intervention, in the whole European population, 44.6% of fractures were treated beyond 72 h from injury; 37.1% of patients underwent treatment within 24 h, and in the remaining 28.3% of cases treatment was performed within 72 h (but after 24 h) from injury. In this specific analysis, the widest variation was observed from centre to centre, as shown in Fig. 10. This finding seems to be associated with local management issues, different protocols in the timing of trauma management, and the timing of referral of trauma patients to a trauma hospital with a maxillofacial department. Finally, the analysis of dates of injury allowed us to calculate the monthly distribution of maxillofacial trauma over the year (Fig. 11): a uniform distribution among all months is noted with slightly higher values during the summer months. 5. Conclusion The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe. Maxillofacial trauma cases due to assaults and falls outnumber those due to RTAs. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. However, men are still the most frequent victims of maxillofacial injuries. Thanks to the EURMAT collaboration, we managed to perform the first prospective multicentre study on maxillofacial trauma epidemiology in a European population. This is the first step for the establishment of appropriate clinical and research priorities for prevention measures in maxillofacial trauma. Further multicentre studies may contribute to this. References Ahmad Z, Nouraei R, Holmes S: Towards a classification system for complex craniofacial fractures. Br J Oral Maxillofac Surg 50: 490e494, 2012 Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98: 166e170, 2004 Al-Khateeb T, Abdullah FM: Craniomaxillofacial Injuries in the United Arab Emirates: a retrospective study. J Oral Maxillofac Surg 65: 1094e1101, 2007 Allareddy V, Allareddy V, Nalliah RP: Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 69: 2613e2618, 2011 Al-Qamachi LH, Laverick S, Jones DC: A clinico-demographic analysis of maxillofacial trauma in the elderly. Gerodontology 29: e147ee149, 2012 Ansari MH: Maxillofacial fractures in Hamedan province, Iran: a retrospective study (1987e2001). J Craniomaxillofac Surg 32: 28e34, 2004 Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, et al: Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64: 408e414, 2006 Bakardjiev A, Pechalova P: Maxillofacial fractures in Southern Bulgaria e a retrospective study of 1706 cases. J Craniomaxillofac Surg 35: 147e150, 2007 Boffano P, Kommers SC, Roccia F, Gallesio C, Forouzanfar T: Fractures of the mandibular coronoid process: a two centres study. J Craniomaxillofac Surg 42: 1352e1355, 2014a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 116: 275e280, 2013a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Infraorbital nerve posttraumatic deficit and displaced zygomatic fractures: a double-center study. J Craniofac Surg 24: 2044e2046, 2013b Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Diplopia and orbital wall fractures. J Craniofac Surg 25: e183e185, 2014b
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Boffano P, Salentijn EG, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar: Closed management by Ginestet hook elevator of V-shaped fractures of the zygomatic arch. J Craniofac Surg 25: 1130e1132, 2014c Brajdi c D, Virag M, Uglesi c V, Aljinovi c-Ratkovi c N, Zajc I, Macan D: Evaluation of sensitivity of teeth after mandibular fractures. Int J Oral Maxillofac Surg 40: 266e270, 2011 Brasileiro BF, Passeri LA: Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102: 28e34, 2006 Cabalag MS, Wasiak J, Andrew NE, Tang J, Kirby JC, Morgan DJ: Epidemiology and management of maxillofacial fractures in an Australian trauma centre. J Plast Reconstr Aesthet Surg 67: 183e189, 2014 Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN: 1,454 mandibular fractures: a 3year study in a hospital in Belo Horizonte, Brazil. J Craniomaxillofac Surg 40: 116e123, 2012 Corre P, Arzul L, Khonsari RH, Mercier J: Facial trauma and multiple trauma. Soins 778: 43e45, 2013 Dediol E: The role of three-dimensional computed tomography in evaluating facial trauma. Plast Reconstr Surg 129: 354ee355e, 2012 Galteland P, Skjelbred P: A nine-year-old girl with a blue eye. Tidsskr Nor Laegeforen 127: 2938e2939, 2007 Gandhi S, Ranganathan LK, Solanki M, Mathew GC, Singh I, Bither S: Pattern of maxillofacial fractures at a tertiary hospital in northern India: a 4-year retrospective study of 718 patients. Dent Traumatol 27: 257e262, 2011 Gerbino G, Boffano P, Bosco GF: Symphyseal mandibular fractures associated with bicondylar fractures: a retrospective analysis. J Oral Maxillofac Surg 67: 1656e1660, 2009a Gerbino G, Boffano P, Tosco P, Berrone S: Long-term clinical and radiological outcomes for the surgical treatment of mandibular condylar fractures. J Oral Maxillofac Surg 67: 1009e1014, 2009b Holmes S: Reoperative orbital trauma: management of posttraumatic enophthalmos and aberrant eye position. Oral Maxillofac Surg Clin North Am 23: 17e29, 2011 Holmes S, Goldner S, Bridle C, Chin-Shong D, Visram K: Evaluation of complex craniomaxillofacial fractures by a new three-dimensional planning system. Br J Oral Maxillofac Surg 44: 416e417, 2006 Key SJ, Ryba F, Holmes S, Manisali M: Orbital emphysema e the need for surgical intervention. J Craniomaxillofac Surg 36: 473e476, 2008 Kokemueller H, Konstantinovic VS, Barth EL, Goldhahn S, von See C, Tavassol F, et al: Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar process fracturesea prospective doublecenter study. J Oral Maxillofac Surg 70: 384e395, 2012 Konstantinovi c VS, Puzovi c D, Anici c B, Jelovac DB: Epidemiological, clinical, and forensic aspects of chainsaw, circular saw, and grinding saw injuries in the maxillofacial region. J Craniofac Surg 21: 1029e1032, 2010 Kostakis G, Stathopoulos P, Dais P, Gkinis G, Igoumenakis D, Mezitis M, et al: An epidemiologic analysis of 1,142 maxillofacial fractures and concomitant injuries. Oral Surg Oral Med Oral Pathol Oral Radiol 114: S69eS73, 2012 Kraft A, Abermann E, Stigler R, Zsifkovits C, Pedross F, Kloss F, et al: Craniomaxillofacial trauma: synopsis of 14,654 cases with 35,129 injuries in 15 years. Craniomaxillofac Trauma Reconstr 5: 41e50, 2012 Laverick S, Patel N, Jones DC: Maxillofacial trauma and the role of alcohol. Br J Oral Maxillofac Surg 46: 542e546, 2008 Laverick S, Siddappa P, Jones DC: Patterns of emergency maxillofacial referrals and provision of services. Br J Oral Maxillofac Surg 47: 99e101, 2009 Lee K: Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr 5: 213e222, 2012 Lekven N, Neppelberg E, Tornes K: Long-term follow-up of mandibular condylar fractures in children. J Oral Maxillofac Surg 69: 2853e2859, 2011 Malanchuk VO, Kopchak AV: Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg 35: 57e62, 2007 McAllister P, Jenner S, Laverick S: Toxicology screening in oral and maxillofacial trauma patients. Br J Oral Maxillofac Surg 51: 773e778, 2013 Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, et al: Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: a 5-year retrospective study. J Craniomaxillofac Surg 42: 227e233, 2014 Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma Prasad R: The pattern of the maxillofacial fractures e a multicentre retrospective study. J Craniomaxillofac Surg 40: 675e679, 2012 Skjelbred P: Management of facial injuries. Tidsskr Nor Laegeforen 112: 1032e1037, 1992 Tamme T, Soots M, Kulla A, Karu K, Hanstein SM, Sokk A, et al: Odontogenic tumours, a collaborative retrospective study of 75 cases covering more than 25 years from Estonia. J Craniomaxillofac Surg 32: 161e165, 2004 Uglesi c V, Virag M, Aljinovi c N, Macan D: Evaluation of mandibular fracture treatment. J Craniomaxillofac Surg 21: 251e257, 1993 van den Bergh B, Heymans MW, Duvekot F, Forouzanfar T: Treatment and complications of mandibular fractures: a 10-year analysis. J Craniomaxillofac Surg 40: e108ee111, 2012a van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T: Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 40: e165ee169, 2012b van den Bergh B, van Es C, Forouzanfar T: Analysis of mandibular fractures. J Craniofac Surg 22: 1631e1634, 2011
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van Hout WM, Van Cann EM, Abbink JH, Koole R: An epidemiological study of maxillofacial fractures requiring surgical treatment at a tertiary trauma centre between 2005 and 2010. Br J Oral Maxillofac Surg 51: 416e420, 2013 Vesnaver A: Open reduction and internal fixation of intra-articular fractures of the mandibular condyle: our first experiences. J Oral Maxillofac Surg 66: 2123e2129, 2008
Vesnaver A, Ah can U, Rozman J: Evaluation of surgical treatment in mandibular condyle fractures. J Craniomaxillofac Surg 40: 647e653, 2012 Vesnaver A, Gorjanc M, Eberlinc A, Dovsak DA, Kansky AA: The periauricular transparotid approach for open reduction and internal fixation of condylar fractures. J Craniomaxillofac Surg 33: 169e179, 2005
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European Maxillofacial Trauma (EURMAT) project: A multicentre and prospective study Paolo Boffano a, *, Fabio Roccia b, Emanuele Zavattero b, Emil Dediol c, Vedran Uglesi c c, c e, Milan Petrovi c e, Ziga Kova ci c d, Ales Vesnaver d, Vitomir S. Konstantinovi f f f f Jonny Stephens , Amar Kanzaria , Nabeel Bhatti , Simon Holmes , Petia F. Pechalova g, Angel G. Bakardjiev g, Vladislav A. Malanchuk h, Andrey V. Kopchak h, Pål Galteland i, Even Mjøen i, Per Skjelbred i, Carine Koudougou j, Guillaume Mouallem j, Pierre Corre j, Sigbjørn Løes k, Njål Lekven k, Sean Laverick l, Peter Gordon l, Tiia Tamme m, Stephanie Akermann m, K. Hakki Karagozoglu a, Sofie C. Kommers a, Tymour Forouzanfar a a Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands b Department of Maxillofacial Surgery, University of Turin, Turin, Italy c Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia d Maxillofacial Department, UKC Ljubljana, Slovenia e Clinic of Maxillofacial Surgery, School of Dentistry, University of Belgrade, Serbia f Department of Oral and Maxillofacial Surgery, Royal London Hospital, Barts Health NHS, London, UK g Department of Maxillo-facial Surgery, Medical University, Plovdiv, Bulgaria h Department for Oral and Maxillo-facial Surgery, Bogomolets National Medical University, Kiev, Ukraine i Department of Maxillofacial Surgery, Oslo University Hospital, Oslo, Norway j Service de Stomatologie et Chirurgie Maxillo-faciale, Chu de Nantes, France k Department of Maxillofacial Surgery, University of Bergen, Bergen, Norway l Department of Oral and Maxillofacial Surgery, NHS Tayside, University of Dundee, Dundee, UK m Department of Maxillofacial Surgery, Stomatology Clinic, Tartu University, Tartu, Estonia
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 1 July 2014 Accepted 15 October 2014 Available online 22 October 2014
The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery over one year. The following data were recorded: gender, age, aetiology, site of facial fractures, facial injury severity score, timing of intervention, length of hospital stay. Data for a total of 3396 patients (2655 males and 741 females) with 4155 fractures were recorded. The mean age differed from country to country, ranging between 29.9 and 43.9 years. Overall, the most frequent cause of injury was assault, which accounted for the injuries of 1309 patients; assaults and falls alternated as the most important aetiological factor in the various centres. The most frequently observed fracture involved the mandible with 1743 fractures, followed by orbital-zygomatic-maxillary (OZM) fractures. Condylar fractures were the most commonly observed mandibular fracture. The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe, with trauma cases caused by assaults and falls now outnumbering those due to road traffic accidents. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. Men are still the most frequent victims of maxillofacial injuries. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Aetiology Assaults Cause Epidemiology Facial fracture Mandible
* 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). http://dx.doi.org/10.1016/j.jcms.2014.10.011 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
P. Boffano et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 62e70
1. Introduction The epidemiology of maxillofacial fractures is extremely variable, depending on several factors such as the geographical area, cultural and lifestyle differences, and socioeconomic trends (Gandhi et al., 2011; Kostakis et al., 2012; Naveen Shankar et al., 2012; Lee, 2012; van Hout et al., 2013). Common causes of facial fractures are road traffic accidents (RTA), assaults, falls, and sports and work injuries (Naveen Shankar et al., 2012). RTAs have often been described as the primary cause of facial fractures (Al-Khateeb and Abdullah, 2007; Chrcanovic et al., 2012; Naveen Shankar et al., 2012), although assaults and interpersonal violence have been found to be the most important aetiological factor by other authors (Mijiti et al., 2014). In recent years, there has been a decreasing trend in RTA-related facial trauma in several developed countries due to changes in road safety legislation. Following the reduction of maxillofacial trauma caused by traffic accidents, interpersonal violence has become increasingly important as an aetiological factor (Kraft et al., 2012; Kostakis et al., 2012). Facial trauma is a huge public health problem because of the significant negative impact on an individual's overall physical and psychological health and also because of the associated socioeconomic consequences that cannot be ignored. The cost of treatment and admission to hospital, the use of hospital resources, and finally the macroeconomic loss of revenue can be significant after such injuries (Lee, 2012; van Hout et al., 2013; Mijiti et al., 2014). Epidemiological analysis of maxillofacial injuries is important to identify the trauma burden and to help develop more efficient ways to plan resource allocation and to deliver care and preventive measures (Lee, 2012; van Hout et al., 2013; Mijiti et al., 2014). The knowledge of the cause, frequency, and severity of maxillofacial fractures plays an important role in establishing effective treatment and prevention measures (Kostakis et al., 2012). However, in the literature, most epidemiological studies on this important topic have been retrospective or based at a single centre. In particular, the lack of a multicentre prospective study on maxillofacial trauma epidemiology in Europe has been observed. Therefore, several European centres that had already shown research experience in maxillofacial trauma decided to collaborate on a prospective multicentre study on facial fracture epidemiology in Europe (Skjelbred, 1992; Uglesi c et al., 1993; Tamme et al., 2004; Vesnaver et al., 2005; Holmes et al., 2006; Bakardjiev and Pechalova, 2007; Galteland and Skjelbred, 2007; Malanchuk and Kopchak, 2007; Key et al., 2008; Laverick et al., 2008; Vesnaver, 2008; Gerbino et al., 2009a,b; Laverick et al., 2009; Konstantinovic et al., 2010; Brajdi c et al., 2011; Holmes, 2011; Lekven et al., 2011; van den Bergh et al., 2011, 2012a,b; Ahmad et al., 2012; Al-Qamachi et al., 2012; Dediol, 2012; Kokemueller et al., 2012; Vesnaver et al., 2012; Boffano et al., 2013a,b, Boffano et al., 2014a,b,c; Corre et al., 2013; McAllister et al., 2013). The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery. The results of this collaboration in a multicentre prospective study on maxillofacial trauma epidemiology over a one-year period are presented here. 2. Material and methods The present study was conducted at several European departments of oral and maxillofacial surgery: the Department of Oral and Maxillofacial Surgery/Pathology at the VU University Medical Center and Academic Centre for Dentistry Amsterdam (Amsterdam, The Netherlands); the Department of Maxillofacial Surgery at the
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University of Turin (Turin, Italy); the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia); the Maxillofacial department at the UKC Ljubljana, (Ljubljana, Slovenia); the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia); the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health NHS (London, UK); the Department of Maxillofacial Surgery at the Medical University (Plovdiv, Bulgaria); the Department for Oral and Maxillofacial Surgery at the Bogomolets National Medical University (Kiev, Ukraine); the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway); the Service de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France); the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway); the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK); and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computer-assisted database that allowed the prospective and continuous recording of all patients hospitalized with maxillofacial fractures in the involved maxillofacial surgical units across Europe, between Monday 31 December 2012 and Sunday 29 December 2013. The following data were recorded for each patient: gender, age, aetiology, aetiology subtype, site of facial fractures, facial injury severity score (FISS) (Bagheri et al., 2006), date of injury, timing of intervention, and length of hospital stay. The following categories of cause of injury were considered: falls, road traffic accidents (RTA), assaults, sport injuries, work injuries, and other causes. Sport injuries were analysed and divided according to the type of sport. Road traffic accidents were classified according to the mechanism of injury (car accident, motorbike accident, pedestrian, bicycle accident, unknown/other). Work injuries were divided according to the type of work: construction workers, factory workers, farm and forestry workers, office workers, other. Fractures were determined from computed tomography scans at admission to hospital and classified as fractures of the mandible, orbital-zygomatic-maxillary complex (OZM), orbit, nose, Le Fort, frontal sinus, and naso-orbital-ethmoid (NOE) fracture. Orbital fractures were subclassified according to the involved walls and Le Fort fractures were divided according to Le Fort types I, II, and III. Frontal sinus fractures were divided according to the involvement of the anterior and/or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extra-articular condyle, intra-articular condyle. Data regarding the timing of intervention (within 24 h from hospitalization, between 24 and 72 h, after 72 h from hospitalization) were collected. Finally, the dates of injury were grouped and analysed according to the month. Patient characteristics were analysed using descriptive statistics.
3. Results Between Monday 31 December 2012 to Sunday 29 December 2013, 3396 patients with a total of 4155 fractures presented to the centres participating in the EURMAT project. Of the 3396 patients with maxillofacial fractures admitted within the study period, 2655 (78.2%) were male and 741 (21.8%) were female, with a male to female ratio of 3.6:1. In the different centres and countries the male to female ratio varied widely, with the highest value encountered in the Kiev centre (Ukraine) study population (9.4:1) and the lowest value that was observed in Amsterdam (The Netherlands) with an M:F ratio of 2.2:1 (Fig. 1).
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Fig. 1. Percentages of males and females in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
The observed mean age was different from country to country, ranging between 29.9 years in the Dundee centre (Scotland, UK) and 43.9 years in Ljubljana (Slovenia). However, most centres presented a mean age that was included in the decade 30e39 years, with the following values: 34.7 in Plovdiv (Bulgaria), 33.6 in Tartu (Estonia), 32.7 in Nantes (France), 38 in Oslo (Norway), 31.9 in Bergen (Norway), 35.4 in Belgrade (Serbia), 32.8 in Kiev (Ukraine), and 34 in London (England, UK) (Fig. 2). In almost all centres the mean age of females was higher or remarkably higher than the males (Table 1). The most important difference was observed in Zagreb (Croatia) where the mean age was 55.8 in females and 38.9 in males. Instead, in Bergen (Norway) an inversion of values was observed with a mean age of 31.2 in women and 32.1 in men. As for aetiology, the most frequent cause of injury was assault with 1309 patients, followed by falls (1050 patients), sport accidents (385 patients), RTAs (375 patients), work accidents (117 patients), and other causes (160 patients) (Fig. 3). The aetiology of maxillofacial injuries changed from centre to centre, with assaults and falls alternating as the most important aetiological factor: assaults were the predominant cause in Plovdiv (Bulgaria), Tartu (Estonia), Oslo (Norway), Belgrad (Serbia), Kiev (Ukraine), London (England, UK), and Dundee (Scotland, UK); whereas falls were the most important aetiological factor in Turin (Italy), Nantes (France), Zagreb (Croatia), Bergen (Norway), Amsterdam (The Netherlands), and Ljubljana (Slovenia) (Fig. 4). In all centres with a mean age higher than 40 years (Turin, Zagreb, Amsterdam, and Ljubljana), falls were the most important cause of maxillofacial trauma. As for RTAs, car accidents were responsible for the trauma in 177 out of the 375 cases (42.7%). Other RTA aetiological factors were
motorbike accidents (91 cases, 24.3%), bicycle accidents (49 cases, 13.1%), pedestrian versus car accidents (33 patients, 8.8%) and other/unknown causes (25 patients, 6.6%). Small variations were observed from country to country, with the exception of Plovdiv and Tartu (where car accidents were responsible for more than 85% of RTAs). In the group of patients with sport-related accidents, soccer was most frequently responsible for maxillofacial injuries (141 patients, 36.6%), followed by rugby (62 cases, 16.1%), skiing (37 patients, 9.6%), basketball (19 cases, 4.9%), hockey (15 patients, 3.9%), and combat sports (9 patients, 2.3%); a total of 102 cases were from unspecified or other sports. The most frequently involved work category in work-related facial fractures was farm and forestry workers. This group of workers presented 35 cases out of 117 (29.9%). Other involved categories were construction workers (32 patients, 27.3%), factory workers (24 cases, 20.5%), office workers (6 patients, 5.2%), and others (20 patients, 17.1%). The percentages of work-related maxillofacial injuries are summarized in Fig. 5. The most frequently observed fracture involved the mandible with 1743 fractures, followed by OZM fractures (1010 fractures), orbital fractures (656), nose fractures (395), Le Fort fractures (195), frontal sinus fractures (110), and NOE fractures (46) (Fig. 6). A noticeable variability was observed in fracture types from country to country (Fig. 7). As for the mandible, 592 condylar fractures were observed, representing the most commonly observed mandibular fracture accounting for the 34% (extracapsular condyle, 26%; intracapsular condyle, 8%). These were followed by body fractures, angle fractures, fractures of the symphyseal region, dentoalveolar fractures,
Fig. 2. Mean age (years) in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
P. Boffano et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 62e70 Table 1 The mean age of female and male patients in the different study centre populations. Centre
Female mean age (years)
Male mean age (years)
Turin, Italy Plovdiv, Bulgaria Tartu, Estonia Nantes, France Zagreb, Croatia Oslo, Norway Bergen, Norway Amsterdam, The Netherlands Ljubljana, Slovenia Belgrad, Serbia Kiev, Ukraine London, England, UK Dundee, Scotland, UK
44.8 36.9 36.1 36.6 55.8 41.8 31.2 43.7 51.5 47.4 37.2 34.2 31.9
39.1 34.2 33.1 31.3 38.9 36.8 32.1 38.9 41.3 33.4 32.4 33.8 29.7
fractures of the ramus, and coronoid fractures in decreasing numbers (Fig. 8). The FISS mean score in the study populations ranged between 1.6 (Nantes) and 3 (Bergen), with a substantial uniformity between all centres. However, the mean hospital stay presented wider differences: the minimum values were observed in Dundee (2 days) and Nantes (2.1 days), whereas the maximum values were encountered in Kiev (10.6 days), Turin (4.8 days), and Zagreb (4.8 days) (Fig. 9). As for timing of intervention, in the whole European population 44.6% of fractures were treated beyond 72 h from injury; 37.1% of patients underwent treatment within 24 h; and in the remaining 28.3% of cases treatment was performed within 72 h (but after 24 h) from injury. In this specific analysis, the widest variation was observed from centre to centre, as shown in Fig. 10. Finally, the analysis of dates of injury allowed us to calculate the monthly distribution of maxillofacial trauma (Fig. 11): a uniform distribution across all months is noted, with slightly higher values during the summer months. 4. Discussion The incidence, aetiology, clinical presentation, and characteristics of maxillofacial fractures are influenced by sociodemographic, economic, and cultural factors of the population studied (Kostakis et al., 2012; Naveen Shankar et al., 2012; Mijiti et al., 2014). This prospective multicentre study was designed to obtain reliable epidemiological data about maxillofacial trauma in Europe. In fact, the collaboration of maxillofacial surgery units across Europe in gathering uniform data allowed a decrease in the bias of patient
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selection and surgical techniques; increased the study population; and gave information about the epidemiology of maxillofacial trauma in different regions. The prevalence of men involved in maxillofacial trauma is strongly supported by previous literature, with male to female ratios ranging between 2:1 to 8:1 (Gandhi et al., 2011; Allareddy et al., 2011; Kostakis et al., 2012; Kraft et al., 2012; Lee, 2012; Mijiti et al., 2014). The present study results also suggest that a larger proportion of patients with maxillofacial fractures are male. In fact, in our study, of the 3396 patients with maxillofacial fractures admitted within the study period, 2655 (78.2%) were male and 741 (21.8%) were female, with a male to female ratio of 3.6:1. This can be explained by the fact that men would be more actively involved in social activities, thus being more susceptible to traffic accidents, interpersonal violence, and work- and sport-related injuries (Kostakis et al., 2012). Although the recent literature shows a trend towards a more equal male to female ratio in the last three decades (Gandhi et al., 2011; Lee, 2012), men still outnumbered women in our study population. However, in the different centres and countries the value of the male to female ratio varied widely, with the maximum value encountered in Kiev (9.4:1) and the minimum value in Amsterdam with an M:F ratio of 2.2:1. In particular, Plovdiv, Tartu, Zagreb, Belgrad, Kiev, and Dundee presented percentages of men above 80%, whereas Turin, Nantes, Oslo, Bergen, Amsterdam, Ljubljana, and London showed percentages of men ranging between 65% and 80% (Fig. 1). Therefore, a tendency to higher male to female ratios could be observed in Eastern Europe, whereas lower male to female ratios were usually found in Western European countries. The gender ratio in facial trauma also changes depending on the cause (Lee, 2012; Mijiti et al., 2014). For example, in almost all the EURMAT centres that presented a percentage of assault related maxillofacial fractures of 40% or higher, men represented more than 80% of the single centre population (Plovdiv, Tartu, Belgrad, Kiev, and Dundee) (Figs. 1 and 4). In the literature, maxillofacial fractures occur most frequently in people aged 20e30 years (Al Ahmed et al., 2004; Ansari, 2004; Brasileiro and Passeri, 2006; Al-Khateeb and Abdullah, 2007; Gandhi et al., 2011; Kraft et al., 2012; Lee, 2012; Mijiti et al., 2014). In the EURMAT collaboration, most centres presented a mean age that was included in the decade from 30 to 39 years (Fig. 2). Furthermore, in almost all centres the mean age of females was higher or remarkably higher than males (Table 1). These results could be due to an increase in life expectancy (especially in women) and the
Fig. 3. Percentages of causes of maxillofacial trauma in the whole EURMAT study population.
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Fig. 4. Percentages of causes of maxillofacial trauma in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
ageing of European people, together with an increasingly active elderly population (Gandhi et al., 2011; Lee, 2012). The aetiology of facial trauma directly affects the incidence, clinical presentation, and treatment modalities of the facial fractures (Mijiti et al., 2014). Therefore, it is a crucial aspect to investigate during epidemiological studies such as ours. In the maxillofacial trauma literature, RTAs, assaults and falls are the leading causes, with a wide range of relative frequencies, depending on the socioeconomic, cultural and environmental factors of the country (Cabalag et al., 2014). Of course, a changing trend in both developing and developed countries could be found in recent articles. In fact, in the developed nations, the major cause of the injuries seems to have become interpersonal violence whereas in developing countries RTAs are still the most important aetiological factor (Al-Khateeb and Abdullah, 2007; Gandhi et al., 2011; Chrcanovic et al., 2012). In the EURMAT collaboration, the most frequent cause of injury was assault, with 1309 patients, followed by falls (1050 patients), sport accidents (385 patients), RTAs (375 patients), work accidents (117 cases), and other causes (160 patients) (Fig. 3). However, as aforementioned, a variation could be observed between centres, but assaults and falls were always the two most important causes (Fig. 4). It was curious to observe that in all centres with a mean age higher than 40 years (Turin, Zagreb, Amsterdam, and Ljubljana), falls were the most important cause of maxillofacial trauma. This strongly supports the fact that falls would be more and more associated with an elderly population. Therefore, the increasing age of the European population could be responsible for the progressive increase of fall-related maxillofacial injuries; this is likely to continue.
It is also be interesting to notice that assaults were the most frequently observed cause in almost all the centres where more than 80% of the injured patients are male (Plovdiv, Tartu, Belgrad, Kiev, and Dundee), thus supporting the association between men and assaults leading to maxillofacial injury. Surprisingly, in the EURMAT population, RTAs were even outnumbered by sport accidents, representing just the fourth cause of maxillofacial trauma as a whole. In particular, car accidents were still responsible for most RTAs (47.2%), followed by motorbike accidents, bicycle accidents, and pedestrian versus car accidents. In sport accidents, football/soccer was the most frequent cause for maxillofacial injuries (36.6%), followed by rugby, skiing, and basketball. The extremely low percentages of RTAs and work accidents could be associated with recent strict road traffic and work safety laws in most European countries. In fact, the implementation of safety norms like mandatory seat belts, air bags, helmet wearing for motorized two-wheelers and speed limits, in addition to strict policies against drinking and driving seem to have contributed to a dramatic decrease in road traffic related maxillofacial trauma. Work accidents could also have been reduced by more efficient safety laws and regulations. The most frequently observed fracture involved the mandible with 1743 fractures (42%), followed by OZM fractures (24%), orbital fractures (16%), nose fractures (9%), Le Fort fractures (5%), frontal sinus fractures (3%), and NOE fractures (1%) (Fig. 6). Previous studies have shown that the mandible is the most common site for maxillofacial fracture, often followed by zygoma as in our population (Ansari, 2004; Al-Khateeb and Abdullah, 2007; Allareddy et al., 2011; Mijiti et al., 2014).
Fig. 5. Percentages of work-related maxillofacial injuries in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
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Fig. 6. Percentages of the different types of maxillofacial fractures in the whole EURMAT study population.
Fig. 7. Percentages of maxillofacial fractures in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Of course, our results in fracture site distribution suffer from an important limitation that characterizes several maxillofacial departments: nose fractures are often treated by ENT departments, thus possibly changing the real epidemiology and percentages of fractures of the facial bones.
As for the mandible, condylar fractures represented the most commonly observed mandibular fracture accounting for the 34%. These fractures were followed by body fractures, angle fractures, fractures of the symphyseal region, dentoalveolar fractures, fractures of the ramus, and coronoid fractures in decreasing numbers.
Fig. 8. Percentages of mandibular fractures in the whole EURMAT study population.
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Fig. 9. FISS and hospital stay values in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Fig. 10. Percentages of timing of intervention in the EURMAT centres. I: Italy; BG: Bulgaria; EST: Estonia; F: France; HR: Croatia; N1: Oslo, Norway; N2: Bergen, Norway; NL: The Netherlands; SLO: Slovenia; SRB: Serbia; UA: Ukraine; UK1: London, England; UK2: Dundee, Scotland.
Our finding was consistent with previous studies (Gandhi et al., 2011). In particular, the high incidence of condylar fracture could be related to the high percentage of fall-related injuries in the EURMAT study population. The present study did not thoroughly examine the different types of treatment for maxillofacial fractures that would strongly
influence the length of hospital stay and the recovery. However, the analysis of FISS mean scores together with length of hospital stays in the various EURMAT centres still gave interesting results. In fact, whereas FISS mean scores showed a substantial uniformity between all centres in the study populations (ranging between 1.6 and 3), mean hospital stays presented wider differences. In contrast
Fig. 11. Percentage of injuries occurring each month in the EURMAT study population.
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with the extremely low values observed in Dundee (2 days) and Nantes (2.1 days), much higher values were found in Kiev (10.6 days), Turin (4.8 days), and Zagreb (4.8 days) (Fig. 9). In addition to the chosen treatment (open or closed), these different values could find an explanation in the differences and peculiarities of the health care systems, the referral of trauma patients directly to the trauma centre, and the postoperative management of maxillofacial trauma patients. As for timing of intervention, in the whole European population, 44.6% of fractures were treated beyond 72 h from injury; 37.1% of patients underwent treatment within 24 h, and in the remaining 28.3% of cases treatment was performed within 72 h (but after 24 h) from injury. In this specific analysis, the widest variation was observed from centre to centre, as shown in Fig. 10. This finding seems to be associated with local management issues, different protocols in the timing of trauma management, and the timing of referral of trauma patients to a trauma hospital with a maxillofacial department. Finally, the analysis of dates of injury allowed us to calculate the monthly distribution of maxillofacial trauma over the year (Fig. 11): a uniform distribution among all months is noted with slightly higher values during the summer months. 5. Conclusion The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe. Maxillofacial trauma cases due to assaults and falls outnumber those due to RTAs. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. However, men are still the most frequent victims of maxillofacial injuries. Thanks to the EURMAT collaboration, we managed to perform the first prospective multicentre study on maxillofacial trauma epidemiology in a European population. This is the first step for the establishment of appropriate clinical and research priorities for prevention measures in maxillofacial trauma. Further multicentre studies may contribute to this. References Ahmad Z, Nouraei R, Holmes S: Towards a classification system for complex craniofacial fractures. Br J Oral Maxillofac Surg 50: 490e494, 2012 Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98: 166e170, 2004 Al-Khateeb T, Abdullah FM: Craniomaxillofacial Injuries in the United Arab Emirates: a retrospective study. J Oral Maxillofac Surg 65: 1094e1101, 2007 Allareddy V, Allareddy V, Nalliah RP: Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 69: 2613e2618, 2011 Al-Qamachi LH, Laverick S, Jones DC: A clinico-demographic analysis of maxillofacial trauma in the elderly. Gerodontology 29: e147ee149, 2012 Ansari MH: Maxillofacial fractures in Hamedan province, Iran: a retrospective study (1987e2001). J Craniomaxillofac Surg 32: 28e34, 2004 Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, et al: Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64: 408e414, 2006 Bakardjiev A, Pechalova P: Maxillofacial fractures in Southern Bulgaria e a retrospective study of 1706 cases. J Craniomaxillofac Surg 35: 147e150, 2007 Boffano P, Kommers SC, Roccia F, Gallesio C, Forouzanfar T: Fractures of the mandibular coronoid process: a two centres study. J Craniomaxillofac Surg 42: 1352e1355, 2014a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 116: 275e280, 2013a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Infraorbital nerve posttraumatic deficit and displaced zygomatic fractures: a double-center study. J Craniofac Surg 24: 2044e2046, 2013b Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Diplopia and orbital wall fractures. J Craniofac Surg 25: e183e185, 2014b
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