Facial fractures in a reference center for Level I Traumas. Descriptive study

(1)

w w w . e l s e v i e r . e s / r e c o m

Revista

Española

de

Cirugía

Oral

y

Maxilofacial

Original

article

Facial

fractures

in

a

reference

center

for

Level

I

Traumas.

Descriptive

study

夽

Edgardo

Gonzalez,

Christian

Pedemonte,

Ilich

Vargas,

Diego

Lazo,

Hernán

Pérez,

Marco

Canales,

Francisco

Verdugo-Avello

∗

UnidaddeCirugíaMaxilofacial,PoliclínicodeEspecialidades,HospitalClínicoMutualdeSeguridadC.Ch.C,Santiago,Chile

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received9June2013 Accepted16September2013 Availableonline23May2015

Keywords:

Maxillofacialtrauma Traumacentre Epidemiology

a

b

s

t

r

a

c

t

Objectives: Theaimofthepresentdescriptivestudy wastorecorddataonmaxillofacial traumainworkingadultsina3year-periodinareferencetraumacentreinChile.

Materialsandmethods:Adescriptivestudywasconductedoncasesofmaxillofacialfractures treatedintheMaxillofacialSurgeryUnitoftheHospitalClínicoMutualdeSeguridad, San-tiagodeChile,overa3-yearperiod.Frequency,typeandcauseofinjury,aswellasageand genderdistributionwereanalysed.

Results:Thestudy populationconsistedof283patients,259(91.5%)malesand24(8.5%) femaleswithameanageof40.5(SD:±20.5)years.In499fracturesiteszygomaticfractures werethemostprevalentlocationofthe499fracturesites,inbothmalesandfemales(48%), followedbyorbitalfractures(27.2%),andjawfractures(21.2%).Themostcommonaffected partofthefacewasisolatedmid-facialfractures.Trafﬁc-accident-relatedfractureswerethe mostcommoncause(39.2%),withthelargestproportionoftheseinvolvingacaraccident.

Discussion: Theresultspresentedareinlinewithotherstudiesandtheanalysisofthisreport providesimportantdataforthedesignofplansforinjuryprevention,especiallyformeasures inroadtrafﬁc.

Fracturas

faciales

en

un

centro

de

referencia

de

traumatismos

nivel

i.

Estudio

descriptivo

Palabrasclave: Traumatismomaxilofacial Centrodetraumatismos Epidemiología

r

e

s

u

m

e

n

Objetivo:Recopilarinformacióndeltraumatismomaxilofacial,especíﬁcamenteenpacientes adultos,enelperiodode3a ˜nosenuncentrochilenodereferenciadetraumatismos.

Materialesymétodos:Serealizóunestudiodescriptivoretrospectivoentodosloscasosde fracturas facialesqueasistieronalServiciode CirugíaMaxilofacial delHospitalClínico Mutual de Seguridad C.Ch.C., Santiago de Chile, en el periodo de 3 a ˜nos (enero de

夽_Please_cite_this_article_as:_Gonzalez_E,_Pedemonte_C,_Vargas_I,_Lazo_D,_Pérez_H,_Canales_M,_et_al._Fracturas_faciales_en_un_centro_de

referenciadetraumatismosniveli.Estudiodescriptivo.RevEspCirOralMaxilofac.2015;37:65–70.

∗ _{Corresponding}_author.

E-mailaddresses:[email protected],[email protected](F.Verdugo-Avello).

(2)

2009-diciembrede2011).Fueronanalizadaslasvariablesydistribucióndegénero,edad, tipo,frecuenciadecadafracturaycausadeltraumatismo.

Resultados: Lapoblaciónestudiadaconsistióen283pacientes,259(91,5%)hombresy24 (8,5%)mujeresconunpromediodeedadde40,5(SD:±20,5)a ˜nos.En499sitiosdefractura lasfracturascigomáticasfueronlalocalizaciónmásprevalenteenambosgéneros(48%), seguidasdelasfracturasorbitarias(27,2%)y entercerlugarlasfracturasmandibulares (21,2%).Lapartedelacaramásafectadafueelterciomedio.Lostraumatismosporaccidente detránsitofueronlacausamáscomún(39,2%);lagranmayoríadeestosfueronporaccidente automovilístico.

Discusión: Losresultadosmostradosenesteartículoestánenlíneaconlaliteratura,yel análisisdeestereporteproveeimportanteinformaciónparaeldise ˜nodeplanesde preven-ciónderiesgos,especialmenteparadesarrollarmedidaseneláreadeltránsito.

Maxillofacialfracturesareanimportantcauseofmorbidity and may lead to both aesthetic and functional conse-quences.Theepidemiologyoftheseinjuriesvariesaccording tothe type, severityand causes depending on the studied population.1,2

Geographicareaandsocio-economicstatusofthe popula-tioncanaffecttheresultsofthedifferentstudies.However, recentstudies showthatdamages inthe maxillofacialand skull areaare usuallyinﬂicted bytrauma,speciﬁcally acci-dentscausedbymotorcycle,assaultsandfalls.3–7

Theaccumulation ofmaxillofacial fractures data inthe longtermisimportant,sinceitallowsthedevelopmentand assessmentofpreventivemeasures.7

Unluckily,therearenodescriptivestudiesaboutpatients withfacialfracturesintheChileanpopulation.Besides,there is few available information regarding the incidences and causes.8

Theaimofthisdescriptivestudyisthecompilationof infor-mationabouttraumaticfacialfracturesinadultpopulation withinareferencecentreoftraumalevelI.

Materials

and

methods

Aretrospectivestudywasconductedincasesoffacialfracture thatweretreatedbytheMaxillofacialSurgeryUnitofHospital ClínicoMutualdeSeguridad(SecurityMutualClinical Hospi-tal),SantiagodeChile,ina3-yearperiod(fromJanuary2009 toDecember2011).

Thisinformationwasacquiredfromtherevisionof elec-tronicclinicalrecords.

Thecauses offacial trauma were classified in five cat-egories: falls, traffic accidents (motorcycle, vehicle, bicycle and pedestrian impact), violence, a blow with an object (toolor industrialmaterial)and industrialaccident. Allthe patientswithmaxillofacialfractures thatweretreatedwith openorclosereductionwereincluded.Facialfractureswere classified in anterior wall of the frontal sinus, zygomatic complex(maxillary-zygomaticcomplexwithorwithout zygo-maticarch),mandibular(symphyseal,parasymphyseal,body, angle,branch,coronoidand condylar),orbital(middlewall, floor and roof), extended fractures like type LeFort I/II/III and pan-facialfracture. Nasal fractures wereexcluded and

pan-facial fractures were considered as one for statistical purposes.

Frequencyvariations,typeandcauseofdamage,aswellas genderand agewere analysed.Thecomparisonswere per-formed through aChi squaretest. This was followed bya logistic regression analysisto determinethe impact ofthe ﬁvefacialtraumacauses.Theﬁnalregressionsampleincluded variationssuchasage,genderandcauseoffacialtrauma.

Thisstudywasapprovedbytheethicscommitteeofthe hospital.

Results

Epidemiology

Thepopulationconsistedof283patients,259(91.5%)maleand 24female(8.5%)withameanageof40.5years(SD:±20.5).The youngestpatientwas18yearsoldandtheoldest76.Themost affectedagerangewasfrom40to49years,followedbythe groupof30–39.Thesetwoagegroupsrepresentedhalfofthe patients(Table1).

Withinatotalamountof499fracture features,themost frequentlocation,inbothgenders,wasthezygomaticfracture (136patients[48%])followedbyorbitalfractures(77patients [27.2%])andmandibularfractures(60patients[21.2%]).More detailsaredisplayedinTable2.Halfofthepatientspresented onlyonefracture,29.3%presentedtwofracturesand15% pre-sented threefractured areas.Themostaffectedfacial area was theisolatedmiddlethird, with184patients(65%), and thelowerthird,with44patients(15.5%)(Fig.1).Fracturesthat presentedcomminutionwereseenin47patients(16.6%)and themostfrequentassociationamongthelocationoffractures were zygomaticfracturestogetherwithorbitalfractures(30 patients [10.6%]).Signiﬁcantdifferences werefoundamong the variables of the facial third and the group of patients (p=0.02).

Traumas caused by trafﬁc accidents were seen in 111 patients(39.2%).Agreatpartofthisgroupwasdueto vehi-cleaccidents(47patients[16.6%]),followedbythepedestrian impact(25patients[8.8%]).Thesecondmostfrequentcause wasviolentacts(67patients[23.6%])followedbyblowwith anobject(44patients[15.5%]).Table1illustratesthecauses

(3)

Table1–Distributionofageandgenderofmaxillofacialfractures.

Agerange Violence Blowwithanobject Industrialaccident Trafﬁcaccident Falls Others Total

10–19 2 1 0 0 1 0 4 20–29 10 7 4 29 10 2 62 30–39 14 12 2 28 13 2 71 40–49 23 12 2 21 11 3 72 50–59 13 9 1 22 7 1 53 60ormore 5 3 1 11 1 0 21 Total 67 44 10 111 43 8 283

Table2–Numberofthefracturelinesrelatedtothefaciallocation.Nasalfractureswereexcludedandpan-facialfractures wereconsideredasone.

Faciallocation Place Totalamountoffracturelines(499)

Upperthird Frontal Frontalsinus 30

Orbitalroof(frontal) 10

Middlethird Zygomaticcomplex Zygomatic 122

Zygomaticarch 67

Jawbone Jawbone 25

LeFortI 16 LeFortII 16 LeFortIII 17 Alveolar 3 Orbit Floor 78 Naso-orbital-ethmoid 13

Inferiorthird Jawbone Symphysis 6

Para-symphysis 18 Body 15 Angle 13 Branch 4 Coronoid 1 Condyle 27 Alveolar 6 Pan-facial 12

oftraumaaccordingtothepatient’sage(Fig.2).Thepeakin theincidenceofvehiclesaccidentswastheagegroupof20–29 yearsoldinbothgenders,whichrepresentshalfofthecauses inthisinterval.Theincidenceofviolenceasacausewashigh

250 200 150 100 50 0 Frontal Patients

Middle third Jaw

Fig.1–Patientswithfacialfracturesaccordingtothefacial thirdlocation.Halfofthepatientspresentedonefracture: 29.3%presentedtwoand15%presentedthreeormore fractures.Therefore,thereismorethanonelocationineach thirdofthepatients.

inthegroupof40–49yearsold.Nosigniﬁcantdifferenceswere foundamongtheagerangesandtheircause.However,there were statisticaldifferencesamongthe facialthirdsand the aetiology(p=0.004).

Mandibularfractures

Therewere60patients(21.2%)withmandibularfractures(55 relatedtothemiddle third),amongwhich90fracture lines werecounted.Twenty-ﬁvepatients(8.8%)presentedasingle fracturefeatureand11(3.8%)presentedtwofeatures.Thetwo majorcausesofmandibularfractureswereviolenceorassault, followedbyvehicleaccidents.Themostfrequentlocationwas thecondyle,followedbytheparasymphysealfractures.The assaultandtrafﬁcaccidentledtoagreatertendencytopresent bodyandparasymphysealfractures,respectively.

Fracturesinthemiddlethird

364fracturefeatureswerecountedamong220patientswith middlethirdtrauma.Inthisgroup,136patientspresented189 fractures inthezygomaticcomplex,88orbital fractures,49 extendedLeFort-typefractures,25mandiblefracturesand13 nasal-orbital-ethmoidfractures(Fig.3).

Amongthese, fracturesin thezygomatic body were the mostcommon.Themaincausesofthesefractureswere vio-lence,falls,andmotorcycleaccidents.Evenmore,60.5%ofthe

(4)

Causes

Traffic accident 39% 4% Blow with an object 16% Fall 15% Violence 24% Others 2% industrial accident

Fig.2–Thecausesof283patientswithmaxillofacial traumaareshown.

fallsand66.7%ofthemotorcycleaccidentsresultedin zygo-maticfracture.Orbitalfractureswereinthesecondplace(77 patients),unleashedmainlybyviolence.Themostcommon compromisedareaofthemwasthelowerorbitalarea(88.6%). The nasal-orbital-ethmoid fractures were present in 13 patients,frequentlyrelatedindecreasingordertothe LeFort-type,pan-facialandzygomaticcomplexfractures.

FracturestypeLeFortIandIIwerefoundin16each,LeFort IIIwere seen in 17patients, while12 patients had a com-binationoffracturesinthree-thirdsofthe face(pan-facial). Themostcommoncauseoftheextendedfacialfractureswas thetrafﬁcaccident,speciﬁcallythosecausedbyvehiclesand pedestrianimpact. No Zygomatic Orbit Le fort Jaw bone 25 0 20 40 60 80 100 120 140 160 Patients 29 88 136 13

Fig.3–Patternoffracturesofthefacialmiddlethird accordingtothenumberofpatients.

Finally,isolatedjawfractureswereseenin25patientsand onerelatedtothenasal-orbital-ethmoidfractures.

Upperthirdoftheface

Intheupperthirdoftheface,40patientssufferedsometype offracture,30ofanteriortableoffrontalsinusand10oforbital roof,mainlycausedbyfallsfromgreathighandtrafﬁc acci-dents.

Openorclosereduction

In this study, titanium plates and screws were used inan open reduction, except for isolated fractures of zygomatic arch,whichweretreatedwithahalf-closedreductionthrough Gilliestechnique.Fromthe283patients,195weresubmitted toatreatmentwithopenreduction.Therestwere orthopaed-ically and/or medically treated. The most common closed treatment was the oneof the zygomatic fractures without displacement(42patients).Insecondplace,orbitalfractures withoutfunctionalcompromise(29patients)withtheorbital groundastheirmostfrequentlocation(71.4%).Thethirdmost commonlocationoffractureswasthemandibularcondyle(18 patients).

Discussion

Chileisacountrywithhighratesofwork-relatedaccidents, whichhasmadeitnecessarytocollectevidenceduringthe last 30 years in order toimplement insurancefor workers in caseofan eventualtraumatic accidentrelated towork. Theseinsurancescreatedcentresoftraumatotreatcomplex severe andchronicillnesses causedbywork.2 _In_our coun-try,itisbindingthattheinsurancecompany(calledMutual) covers the totalamount ofthe workingpopulationagainst consequencesrelatedtowork-relatedaccidentsandthe dis-placementtowardsthisone.ThehospitalMutualdeSeguridad onlyinsuresadultworkers,whichmeansthatchildren, stu-dents,hosewives,aswellasadultsolderthan65yearsoldare notforeseenunderthislaw.Nevertheless,the work-related accidentlawallowsanidentiﬁcationofadiverseadult popu-lationwitharelativehighnumberofcases.

Thisstudydescribestheepidemiologyof283patientswith facialfracturesexceptfornasal fractures.Themale–female ratiowas10:1.Thepredominanceofthemalegenderinthis population ofpatientsisaconstant ﬁnding inmostofthe studies.However,thisproportionwashigherthanwhatwas indicatedinothercountries.9–11_The_population_in_our_study tendstobeolderthaninotherstudies,probablybecause chil-drenunder18yearsoldareexcludedfromtheaverage.

The zygomatic complex,the orbitand the maxillofacial fractureswerethemainlocations,amountingto72%ofthe fracture locations. Previous studies indicate that the most commoncauseoffacialfracturesvariesfromplacetoplace. Withtheexceptionofsomestudies,themostcommoncause of this injury isthe trafﬁcaccident.12 _In _this _regards,_it _is believed that, generally, the percentage of facial fractures caused by vehicle accidents hasdecreased. This isdue to thepreventiveeducation,suchaspromotionalcampaignsof

(5)

seatbeltuseinvehiclesandthelawonrestrictionofalcohol consumptionwhiledriving.13 _Other_studies_have_evidenced thatassaults are the mostfrequentcause.14–16 _The_reason whytheactsofviolencearethesecondmostcommoncause offacialfracturesinSantiagoisdistinguishedwhen consid-eringthesocioculturalstratum.Thematterofviolenceasa primarycauseoffacialfractureamongotherpopulationshas beendiscussed invarious studieswithsubstantialanalysis thatalcoholisacontributingfactor,17_which_may_be_similar_in thisgeographicalarea.

Theresultsinthisreportshowtrafficaccident,especially vehicleaccident,astheprincipalcause.Thiswasparticularly significantinthegroupfrom20to29yearsold.Unlikeother studies,thegroupfrom40to49yearsoldwasthemost rep-resentativegroup.18,19 _Ironically,_the_most_common_cause_of this groupwas the actsofviolence.These findings can be comparedwithseveralotherreports.18–20

With the exception of the mandibular fractures, there isscarce knowledge about the relation between the cause of facial fractures and the location in the middle third. Ellis et al.14 _analysed ₂₀₆₇_cases _of_{orbital-zygomatic} frac-tures, showing the front-zygomatic stitch as the most frequentlyassociatedwithmotorcycle accidents.Ourstudy evidencesthatthefracturesofthezygomaticcomplexwere frequently observed among patients injured due to falls. This study also shows that the strength tends to impact in the lateral side of the face when it comes to vehi-cle accidents. Even more, 60.4% of the falls in this report causeda zygomatic fracture, 22%ofthese were associated with an orbital component, which suggests an exhaustive orbitalexaminationbecauseofthepresenceofazygomatic fracture.

Thesecondmostfrequentfracturesweretheorbital frac-tures,whichaffected 77patientswithviolenceasthemain factor,followedbyvehicleaccidents,blowswithobjectsand industrialaccidentsinequalamount.Theepidemiologyabout this trauma was similar to other studies;21,22 _72.3% _were treatedwithanorbitalreconstructiontitaniummesh.

Asregardsthelowerthirdormandibulararea,itwasfound onlyin21.2%ofthetotalamountofpatients.Previousstudies evidencethatthejawandnasalbonesarethetwomost fre-quentlocationsofmaxillofacialfractures.18,22–24_We_excluded nasalfractures becauseitisatreatmentcarriedoutbythe otolaryngologiststeaminourhospital.Thepossible explana-tionforthelowpercentageobtainedinthisstudyisunknown. However,itispossiblethatthesefracturesprevailwhenthe causesoftraumaare violenceandfalls,15 _unlike_our_study, wheretrafﬁcaccidentwaspredominant.

Thisanalysisreveals the facial fractures’pattern inthe Chileanworkingpopulation.Nevertheless,thisstudypresents severalrestrictions.InSantiago,therearethreehospitalsthat insure workers.They constitute the AsociaciónChilena de Seguridad(ChileanSecurityAssociation).Allthehospitalsin Chile(public,privateandmutualhospitals)treatpatientswith facialfractures;however,someofthemreceivemorepatients thanothers.Thus,theothertwoentitiesareoutofthissample. Wok-relatedaccidentsaretreatedbythesemutualinsurance companies,whiletheaccidentsduetoalcoholconsumption andtraumasnotrelatedtowork aretreatedinprivateand public hospitals. Therefore, it is questionable whether the

resultsofourstudycouldbeextrapolatedtothewhole pop-ulationofSantiago.Forthisreason,multi-centrestudiesare necessary.

Besides,likeotherretrospectivestudies,thisretrospective descriptivestudycanbesubjecttobiasesofinformation. How-ever,thesepresentedresultsareinlinewithotherstudies.In addition,theanalysisofthisreportbringsimportant informa-tionforthedesignofdamagepreventionschemes,especially aboutthemeasuresofthetrafﬁcdisplacement.

Ethical

disclosures

Protection of human and animal subjects.The authors declarethatnoexperimentswereperformedonhumansor animalsforthisstudy.

Conﬁdentialityofdata.Theauthorsdeclarethattheyhave fol-lowedtheprotocolsoftheirworkcenteronthepublicationof patientdata.

Righttoprivacyandinformedconsent.Theauthorsdeclare thatnopatientdataappearinthisarticle.

Conﬂict

of

interest

Theauthorsdeclarethattherearenoconﬂictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.HaugRH,FossJ.Maxillofacialinjuriesinthepediatricpatient. OralSurgOralMedOralPathol.2000;90:126–34.

2.GirottoJA,MacKenzieE,FowlerC,RedettR,RobertsonB, MansonPN:.Long-termphysicalimpairmentandfunctional outcomesaftercomplexfacialfractures.PlastReconstrSurg. 2001;108:312–27.

3.LinS,LevinL,GoldmanS,PeledM.Dento-alveolarand maxillofacialinjuries–aretrospectivestudyfromalevel1 traumacenterinIsrael.DentTraumatol.2007;23:155–7. 4.BooleJR,HoltelM,AmorosoP,YoreM.5,196mandibular

fracturesamong4,381activedutyarmysoldiers,1980to1998. Laryngoscope.2001;11:1691–6.

5.IidaS,KogoM,SugiuraT,MimaT,MatsuyaT.Retrospective analysisof1,502patientswithfacialfractures.IntJOral MaxillofacSurg.2001;30:286–90.

6.BatainehAB.Aetiologyandincidenceofmaxillofacial fracturesinthenorthofJordan.OralSurgOralMedOral PatholOralRadiolEndod.1998;86:31–5.

7.HoggNJ,StewartTC,ArmstrongJE,GirottiMJ.Epidemiology ofmaxillofacialinjuriesattraumahospitalsinOntario, Canada,between1992and1997.JTrauma.2000;49:425. 8.RojasRA,JuliánG,LankinJ.Mandibularfractures.Experience

inatraumahospital.RevMedChil.2002;130:537–43. 9.TimoneyN,SaiveauM.Acomparativestudyofmaxillofacial

traumainBristolandBordeaux.JCranioMaxillofacSurg. 1990;18:154–7.

10.VetterJD,TopazianRG,GoldbergMH.Facialfractures occur-ringinamediumsizedmetropolitanarea:recent trends.IntJOralMaxillofacSurg.1991;20:348.

11.BatainehAB.Etiologyandincidenceofmaxillofacialfractures innorthofJordan.JOralSurgOralMedOralPathol.1998; 86:31.

(6)

12.LeeJH,ChoBK,ParkWJ.A4-yearretrospectivestudyoffacial fracturesonJeju.KoreaJCraniomaxillofacSurg.

2010;38:192–6.

13.LeeKH,SnapeL,SteenbergLJ,WorthingtonJ.Comparison betweeninterpersonalviolenceandmotorvehicleaccidents intheaetiologyofmaxillofacialfractures.ANZJSurgAug. 2007;77:695–8.

14.EllisE,El-AttarA,MoosKF.Ananalysisof2,067casesof zygomatico-orbitalfractures.JOralMaxillofacialSurg. 1985;43:417–28.

15.EllisE,MoosKF,El-AttarA.Tenyearsofmandibularfractures. Ananalysisof2,137cases.OralSurg.1985;59:120–9.

16.ShererM,SullivenWG,SmithDJ,PhillipsLG,RobsonMC.An analysisof1423facialfracturesin788patientsatanurban traumacenter.JTrauma.1989;29:388–90.

17.LeeBT,DierksEJ,UeeckBA,HomerLD,PotterBF.Maxillofacial injuriesassociatedwithdomesticviolence.JOralMaxillofac Surg.2001;59:1277–83.

18.BakardjievA,PechalovaP.MaxillofacialfracturesinSouthern Bulgaria–aretrospectivestudyof1,706cases.J

CraniomaxillofacSurg.2007;35:147–50.

19.AdebayoET,AjikeOS,AdekeyeEO.Analysisofthepatternof maxillofacialfracturesinKaduna,Nigeria.BrJOralMaxillofac Surg.2003;41:396–400.

20.IidaS,KogoM,SugiuraT,MimaT,MatsuyaT.Retrospective analysisof1,502patientswithfacialfractures.IntJOral MaxillofacSurg.2001;30:286–90.

21.MohajeraniSH,AsghariS.Patternofmid-facialfracturesin Tehran.IranDentTraumatol.2011;27:131–4.

22.LeeKH.Interpersonalviolenceandfacialfractures.JOral MaxillofacSurg.2009;67:1878.

23.AllareddyV,AllareddyV,NalliahRP.Epidemiologyoffacial fractureinjuries.JOralMaxillofacSurg.2011;69:2613–8. 24.HwangK,YouSH.Analysisoffacialbonefractures:an

11-yearstudyof2,094patients.IndianJPlastSurg.2010; 43:42.