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Risk factors associated with facial fractures.

Introduction

Maxillofacial trauma is one of the major challenges for public healthcare services due to the a high incidence rate and financial cost. (1) The injuries result from falls, physical aggression and accidents involving motor vehicles, bicycles, animals and sports. (2,3) The epidemiology of trauma is determined by the geographic area, demographic and socioeconomic factors and the period of investigation. (4-7)

The most frequent maxillofacial injuries are fractures of the mandible and bones of the middle third of the face. (3,8-10) Motorcycle accidents, the male gender and the third decade of life are reported to be the main risk factors for facial fractures. (9,10)

The identification of groups at risk, the assessment of the needs of healthcare services and the development of preventive programs and clinical protocols for the treatment of maxillofacial trauma depend directly on knowledge regarding the specific situation of different communities. A critical analysis of the literature reveals that most studies on facial injuries are limited to data of a predominantly descriptive nature, which compromises the quality of the evidence and the correct interpretation of the findings.

The aim of the present study was to identify risk factors for facial fractures in patients treated in the emergency department of a hospital.

Methodology

A retrospective study was performed and involved a chart review of patients treated in the emergency department of a Regional Hospital in the city of Guanhaes, Minas Gerais, Brazil, between January 2005 and December 2007. This hospital is a referral center for 23 municipalities in the Rio Doce valley and treats patients from both urban and rural areas, covering an area of 12,745.1 [km.sup.2] and encompassing a population of 238,797 inhabitants.

The inclusion criterion was a completed patient chart. A total of 1121 charts were analyzed with regards to socio-demographic data, fractured facial bones and etiology.

Descriptive statistics were performed for the socio-demographic data, maxillofacial trauma (soft tissue injuries, facial bone fractures and dentoalveolar trauma) and type of accident. The chi-square and Fisher's exact tests were used to determine associations between facial fractures (mandible, zygoma, maxilla, nose and more than one facial bone) and gender, age, place of residence (urban or rural area) and type of accident. The level of significance was set at 5%. Univariate and multivariate regression analyses were performed for the investigation of risk factors for facial fractures. A regression analysis was performed for each fractured facial bone (dependent variable). To avoid the overestimation of the odds ratio (OR), Poisson analyses were performed when the type of trauma was greater than 10% in the population studied. When the outcome frequency was less than 10%, a logistic regression analysis was performed. Independent variables with a p-value < 0.20 using the chi-square test were incorporated into the regression analysis. The Statistical Package for Social Sciences (SPSS for Windows, version 15.0, SPSS Inc., Chicago, USA) was used for the analyses.

The present study was approved by the Research Ethics Committee of the public hospital at which it was carried out.

Results

Maxillofacial trauma was recorded in 790 charts (70.5%), with 393 (35.1%) charts reporting facial fractures. Table 1 displays the data on the sociodemographic variables and types of accidents. The most frequently fractured facial bone was the mandible (18.0%), the most frequent dentoalveolar trauma was concussion (78.0%) and the most frequent soft tissue injury was contusion (82.4%).

Table 2 displays the prevalence of facial bone fractures according to gender. Fractures of the mandible and zygomatic bone were more prevalent beginning at 13 years of age (Table 3). Mandibular fractures were the most frequent type of fracture among individuals involved in automobile and motorcycle accidents (23.7% and 52.8%, respectively). Of those subjects involved in bicycle accidents 14.9% suffered mandibular fractures, and 14.9% suffered nasal bone fractures. Of those subjects involved in accidents with animals, 30.6% suffered mandibular fractures, and 29.7% suffered zygomatic bone fractures. Of those subjects who were victims of violence, 28.0% suffered mandibular fractures. Of those subjects involved in sport-related accidents, 17.3% suffered zygomatic bone fractures, and 17.9% suffered nasal bone fractures (Table 4).

Motorcycle accident was the main risk factor for fractures of the mandible (PR = 1.576, CI = 1.402-1.772) (Table 5) and more than one facial bone (OR = 4.625, CI = 1.888-11.329), and it was the only risk factor for maxillary fractures (OR = 11.032, CI = 5.294-22.989) (Table 6). Fractures of the zygomatic bone and nose were mainly associated with accidents involving animals (PR = 1.206, CI = 1.104-1.317) and sports (OR = 8.710, CI = 4.006-18.936), respectively (Table 5 and 6).

Discussion

The occurrence of maxillofacial trauma was more prevalent in male patients and in the age group between 20 and 29 years, which corroborates findings described in the literature. (10-12)

The incidence of facial fractures tends to increase with age, (13-15) which was confirmed in the present study. A comparison of individuals under 13 years of age and other age groups revealed a considerable increase in the number of fractures of the mandible and zygomatic bone. The lower incidence of facial fractures among children may be explained by the greater protection offered by the family, which leads to less exposure to injuries stemming from accidents. However, social habits change as a child grows, including school attendance and participation in sports and activities that involve bodily contact, thereby increasing the risk of trauma. (16) Another explanation is the bone structure of children. The lack of pneumatization of the paranasal sinuses and the presence of an ample tooth to bone proportion tend to make a child's facial skeleton more elastic and stable. Moreover, the suture lines are flexible and children have ample fat pads that absorb the impact and reduce the force transmitted to the bone architecture. (17-19)

The mandible was the most commonly affected facial bone (18.1%), which confirms the findings of previous studies. (5,6,9) The greater frequency of mandibular fractures may be explained by the mobility of this structure and its involvement in complex physiological functions due to its prominent position in relation to the facial skeleton as well as its lack of protection. (9,20) A greater frequency of this type of injury is found in children, adolescents and adults alike. (7,9)

Mandibular fractures are more frequently associated with motorcycle accidents (7,9) and physical aggression. (12) In the present study, mandibular fractures were mainly related to motorcycle accidents (52.8%), followed by accidents involving animals (30.6%) and violence (28.0%). The univariate Poisson regression revealed that motorcycle accidents were the only predictive factor for mandibular fractures. However, the multivariate analysis indicated that accidents involving animals and violence were also causes for this type of injury.

The lowest incidence rates of mandibular fractures were found among individuals who had suffered an automobile (23.7%) or a bicycle accident (14.9%). According to Munante-Cardenas et al., (13) the most common causes of mandibular fractures in children and adolescents are bicycle accidents and falls. However, in another study involving Brazilian subjects, soft tissue abrasions, hematomas and dentoalveolar traumas were more commonly associated with bicycle accidents. According to the authors, the explanation for this is in the lesser force of impact experienced during a bicycle accident. (9)

Fracture of the zygomatic bone was more prevalent in accidents involving animals and sports (29.7% and 17.3%, respectively). Our study confirmed these trauma mechanisms as risk factors for this type of injury. A study involving Malaysian subjects showed that 53.6% of zygomatic fractures were due to motorcycle accidents. Individuals involved in this type of accident had a significantly greater incidence of facial fractures. (10,19)

In the present study, motorcycle accidents accounted for a large percentage of mandibular fractures (52.8%). Of these accidents, 23% also had maxillary fractures. In the multivariate logistic regression, individuals who had suffered a motorcycle accident had an 11-fold increase in the risk of also suffering a maxillary fracture. Violence and accidents involving animals accounted for 24.9% and 20.1% of facial fractures, respectively. The large percentage of accidents involving animals stems from the region in which the study was conducted, as the main source of income in this region is livestock farming.

In the present study, fractures of the maxilla and more than one facial bone were more prevalent in motorcycle accidents. Multivariate analysis revealed that individuals who had motorcycle accidents had a 4.62-fold greater risk of suffering fractures in more than one facial bone. A study relating facial trauma to motorcycle accidents found that a considerable number of motorcyclists wear a helmet without the protective visor or wear the helmet in an incorrect fashion and others experience impact of the face against the helmet. (9) Another study involving Brazilian subjects found that 40% of motorcyclists who had suffered accidents were not wearing a helmet, and the majority (60.5%) of victims who wore a helmet were not using a protective visor. (4)

Sports, bicycle accidents and violence were the trauma mechanisms that most frequently led to nasal bone fractures and were confirmed in the multivariate logistic regression as risk factors for this type of injury. Bicycle accidents and violence increased the likelihood of nasal bone fractures by approximately 7-fold, while accidents related to sports resulted in an 8-fold increase. According to the literature, even when cyclists wear helmets, the face remains unprotected, as protection is restricted to the head (with a reduction in the severity of head trauma) and in part to the upper face. (21) While falls accounted for a significant percentage of facial fractures in our study (14.6%), these events did not indicate risk factors for these types of injuries, as only seven individuals suffered facial fractures from a fall. Yamamoto et al. (19) assessed facial fractures resulting from falls and found that two thirds of these fractures involved the mandible.

The findings in our study highlight the importance of public awareness regarding etiology and preventative measures for maxillofacial trauma. Moreover, this study provides consistent evidence regarding the risk factors of facial fractures and can serve as a reference for communities with a similar profile.

Conclusion

Motorcycle accident was the main cause for the majority of facial fractures, followed by accidents involving animals and sports.

Acknowledgments

This study was supported by the Brazilian Coordination of Higher Education (CAPES), the Ministry of Education, the National Council for Scientific and Technological Development (CNPq), the Ministry of Science and Technology and the State of Minas Gerais Research Foundation (FAPEMIG), Brazil.

References

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(2.) Allareddy V, Allareddy V, Nalliah RP. Epidemiology of Facial Fracture Injuries. J Oral Maxillofac Surg. 2011 Oct;69(10):2613-8.

(3.) Thoren H, Numminen L, Snall J, Kormi E, Lindqvist C, Iizuka T, et al. Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg. 2010 Aug;39(8):774-8.

(4.) Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg. 2001 Aug;30(4):286-90.

(5.) 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. 2006 Jul;102(1):28 34.

(6.) Ramli R, Rahman NA, Rahman RA, Hussaini HM, Hamid AL. A retrospective study of oral and maxillofacial injuries in Seremban Hospital, Malaysia. Dent Traumatol. 2011 Apr;27(2):122-6.

(7.) Chrcanovic BR. Factors influencing the incidence of maxillofacial fractures. Oral Maxillofac Surg. 2011 Jun 9. [Epub ahead of print]. doi: 10.1007/s10006-011-0280-y.

(8.) Cheema S, Amin F. Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan. Br J Oral Maxillofac Surg. 2006 Jun;44(3):232-4.

(9.) Lima Junior SM, Santos SE, Kluppel LE, Asprino L, Moreira RW, de Moraes M. A comparison of motorcycle and bicycle accidents in oral and maxillofacial trauma. J Oral Maxillofac Surg. 2011 Jun 10. [Epub ahead of print]. doi: 10.1016/j. joms.2011.03.035.

(10.) Hashim H, Iqbal S. Motorcycle accident is the main cause of maxillofacial injuries in the Penang Mainland, Malaysia. Dent Traumatol. 2011 Feb;27(1):19-22.

(11.) Elhammali N, Bremerich A, Rustemeyer J. Demographical and clinical aspects of sports-related maxillofacial and skull base fractures in hospitalized patients. Int J Oral Maxillofac Surg. 2010 Sep;39(9):857-62.

(12.) Desai J, Lownie JF, Cleaton-Jones P. Prospective audit of mandibular fractures at the Charlotte Maxeke Johannesburg Academic Hospital. S Afr J Surg. 2010 Nov;48(4):122-6.

(13.) Munante-Cardenas JL, Asprino L, de Moraes M, Albergaria-Barbosa JR, Moreira RW. Mandibular fractures in a group of Brazilian subjects under 18 years of age: a epidemiological analysis. Int J Pediatr Otorhinolaryngol. 2010 Nov;74(11):1276-80.

(14.) Qudah MA, Al-Khateeb T, Bataineh AB, Rawashdeh MA. Mandibular fractures in Jordanians: a comparative study between young and adult patients. J Craniomaxillofac Surg. 2005 Apr;33(2):103-6.

(15.) Infante-Cossio P, Espin-Galvez F, Gutierrez-Perez JL, GarciaPerla A, Hernandez Guisado JM. Mandibular fractures in children. A retrospective study of 99 fractures in 59 patients. Int J Oral Maxillofac Surg. 1994 Dec;23(6 Pt 1):329-31.

(16.) Zerfowski M, Bremerich A. Facial trauma in children and adolescents. Clin Oral Investig. 1998 Sep;2(3):120-4.

(17.) Yarington CT Jr. Maxillofacial trauma in children. Otolaryngol Clin North Am. 1977 Feb;10(1):25-32.

(18.) Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofac Surg. 1993 Aug;51(8):836-44.

(19.) Yamamoto K, Kuraki M, Kurihara M, Matsusue Y, Murakami K, Horita S, et al. Maxillofacial fractures resulting from falls. J Oral Maxillofac Surg. 2010 Jul;68(7):1602-7.

(20.) Leporace AA, Paulesini Junior W, Rapoport A, Denardin OV. Epidemiologic study of mandible fractures in a public hospital of Sao Paulo. Rev Col Bras Cir. 2009 Dec;36(6):472-7.

(21.) Thompson DC, Thompson RS, Rivara FP, Wolf ME. A case-control study of the effectiveness of bicycle safety helmets in preventing facial injury. Am J Public Health. 1990 Dec;80(12):1471-4.

Anne Margareth Batist (a)

Fernanda de Oliveira Ferreira (b)

Leandro Silva Marques (c)

Maria Leticia Ramos-Jorge (a)

Meire Coelho Ferreira (a)

(a) Department of Dentistry, School of Biological and Health Sciences, Federal University of Jequitinhonha and Mucuri Valleys, Diamantina, MG, Brazil.

(b) Department of Basic Sciences, School of Biological and Health Sciences, Federal University of Jequitinhonha and Mucuri Valleys, Diamantina, MG, Brazil.

(c) Department of Orthodontics, School of Dentistry, University of Rio Verde Valley, Tres Coragoes, MG, Brazil.

Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

Corresponding author:

Meire Coelho Ferreira

E-mail: meirecofe@ig.com.br

Received for publication on Oct 28, 2011

Accepted for publication on Jan 10, 2012
Table 1--Absolute and relative
frequency of socio-demographic
variables and types of accidents,
Guanhaes, Brazil, 2005-2007
(n = 790).

Variables               n (%)

Gender

Male                 537 (68.0)
Female               253 (32.0)

Age

<13 years             83 (10.5)
13 to 19 years       205 (25.9)
20 to 29 years       317 (40.1)
30 years or older    185 (23.4)

Place of residence

Urban area           534 (67.6)
Rural area           256 (32.4)

Type of accident

Automobile             59 (7.5)
Motorcycle             72 (9.1)
Bicycle               87 (11.0)
Involving animal     111 (14.1)
Work-related           40 (5.1)
Violence             150 (19.0)
Sports               162 (20.5)
Fall                 115 (14.6)

Table 2--Distribution of facial fractures based on gender,
Guanhaes, Brazil, 2005-2007 (n = 393).

Type of           Prevalence     Prevalence      Total (%)
facial fracture   within male    within female
                  gender n (%)   gender n (%)

Mandible           101 (18.8)       41 (16.2)    142 (18.0)
Zygoma              91 (16.9)        11 (4.3)    102 (12.9)
Maxilla              32 (6.0)        10 (4.0)      42 (5.3)
Nose                54 (10.1)        19 (7.5)      73 (9.2)
More than one        30 (5.6)         4 (1.6)      34 (4.3)
  facial bone

Table 3--Distribution of facial fractures based on age group,
Guanhaes, Brazil, 2005-2007 (n = 393).

Type of facial                 Age group
fracture
                 < 13 years   13-19 years   20-29 years
                   n (%)         n (%)         n (%)

Mandible          5 (6.0)      30 (14.6)     74 (23.3)
Zygoma            3 (3.6)      30 (14.6)     42 (13.2)
Maxilla           3 (3.6)       7 (3.4)      16 (5.0)
Nose              8 (9.6)      19 (9.3)      26 (8.2)
More than one     2 (2.4)       4 (2.0)      10 (3.2)
  facial bone

Type of facial   Age group
fracture
                 30 years    Total (%)
                 or older
                   n (%)

Mandible         33 (17.8)   142 (18.0)
Zygoma           27 (14.6)   102 (12.9)
Maxilla          16 (8.6)     42 (5.3)
Nose             20 (10.8)    73 (9.2)
More than one    18 (9.7)     34 (4.3)
  facial bone

Table 4--Distribution of facial fractures based on
type of accident, Guanhaes, Brazil, 2005-2007 (n = 393).

Type of     Automobile   Motorcycle    Bicycle
facial       accident     accident    accident
fracture      n (%)        n (%)        n (%)

Mandible    14 (23.7)    38 (52.8)    13 (14.9)
Zygoma       2 (3.4)      7 (9.7)      4 (4.6)
Maxilla      3 (5.1)     17 (23.6)     4 (4.6)
Nose         0 (0.0)      3 (4.2)     13 (14.9)
More than    2 (3.4)      8 (11.1)     5 (5.7)
  one
  facial
  bone

Type of       Accident       Work     Violence
facial       involving     accident     n (%)
fracture    animal n (%)    n (%)

Mandible     34 (30.6)     0 (0.0)    42 (28.0)
Zygoma       33 (29.7)     6 (15.0)   21 (14.0)
Maxilla       5 (4.5)      3 (7.5)     6 (4.0)
Nose          1 (0.9)      1 (2.5)    22 (14.7)
More than     6 (5.4)      3 (7.5)     7 (4.7)
  one
  facial
  bone

Type of      Sports     Falls      Total
facial       n (%)      n (%)      n (%)
fracture

Mandible     0 (0.0)   1 (0.9)   142 (18.0)
Zygoma      28(17.3)   1 (0.9)   102 (12.9)
Maxilla      3 (1.9)   1 (0.9)    42 (5.3)
Nose        29(17.9)   4 (3.5)    73 (9.2)
More than    3 (1.9)   0 (0.0)    34 (4.3)
  one
  facial
  bone

Table 5--Univariate and multivariate Poisson regression for fractures
of the mandible and zygoma, Guanhaes, Brazil, 2005-2007 (n = 393).

Dependent    Independent variables   Unadjusted     95% CI        p
variables                                PR

Mandibular   Motorcycle accident       1.811      1.282-2.558   0.001
  fracture   Accident involving        1.212      0.956-1.538   0.113
               animal
             Violence                  1.172      0.953-1.441   0.132
             Age
             * < 13 years              1
             * 13-19 years             0.918      0.855-0.984   0.017
             * 20-29 years             0.841      0.785-0.901   0.000
             * 30 years or older       0.889      0.824-0.958   0.002
Zygomatic    Place of residence
  fracture   * Urban area              1.114      0.946-1.311   0.194
             * Rural area              1
             Accident involving        1.278      1.010-1.618   0.041
               animal
             Sports                    1.066      0.883-1.288   0.504
             Age
             * < 13 years              1
             * 13-19 years             0.896      0.841-0.954   0.001
             * 20-29 years             0.908      0.860-0.959   0.001
             * 30 years or older       0.896      0.840-0.956   0.001

Dependent    Independent variables   Adjusted     95% CI        p
variables                               PR

Mandibular   Motorcycle accident      1.576     1.402-1.772   0.000
  fracture   Accident involving       1.268     1.159-1.388   0.000
               animal
             Violence                 1.231     1.139-1.329   0.000
             Age
             * < 13 years             1
             * 13-19 years            0.983     0.906-1.066   0.681
             * 20-29 years            0.931     0.860-1.007   0.076
             * 30 years or older      0.958     0.879-1.044   0.330
Zygomatic    Place of residence
  fracture   * Urban area             1.057     1.003-1.115   0.040
             * Rural area             1
             Accident involving       1.206     1.104-1.317   0.000
               animal
             Sports                   1.111     1.040-1.187   0.002
             Age
             * < 13 years             1
             * 13-19 years            0.928     0.869-0.991   0.025
             * 20-29 years            0.925     0.874-0.979   0.007
             * 30 years or older      0.906     0.847-0.968   0.003

PR: prevalence ratio. 95% CI: 95% confidence interval.

Table 6--Univariate and multivariate logistic regression for
fractures of the maxilla, nose and more than one facial bone,
Guanhaes, Brazil, 2005-2007 (n = 393).

Dependent         Independent      Unadjusted      95% CI        p
variables         variables            OR

Maxillary    Motorcycle accident     8.568      4.364-16.820   0.000
  fracture   Age
             * < 13 years            1
             * 13-19 years           0.943      1.238-3.737    0.933
             * 20-29 years           1.417      0.403-4.985    0.587
             * 30 years or older     2.525      0.715-8.914    0.150
Nasal        Place of residence
  fracture   * Urban area            1
             * Rural area            0.466      0.255-0.851    0.013
             Bicycle accident        1.883      0.987-3.592    0.055
             Violence                1.985      1.162-3.390    0.012
             Sports                  2.894      1.746-4.796    0.000
Fracture     Motorcycle accident     3.327      1.447-7.651    0.005
  of more    Age
  than one   * < 13 years            1
  facial     * 13-19 years           0.806      0.145-4.487    0.805
  bone       * 20-29 years           1.319      0.283-6.140    0.724
             * 30 years or older     4.365      0.989-19.268   0.052

Dependent         Independent      Adjusted      95% CI        p
variables         variables           OR

Maxillary    Motorcycle accident    11.032    5.294-22.989   0.000
  fracture   Age
             * < 13 years           1
             * 13-19 years          0.811     0.196-3.356    0.772
             * 20-29 years          0.901     0.242-3.351    0.876
             * 30 years or older    2.779     0.755-10.222   0.124
Nasal        Place of residence
  fracture   * Urban area           1
             * Rural area           0.596     0.321-1.108    0.102
             Bicycle accident       7.008     2.881-17.049   0.000
             Violence               6.857     3.068-15.326   0.000
             Sports                 8.710     4.006-18.936   0.000
Fracture     Motorcycle accident    4.625     1.888-11.329   0.001
  of more    Age
  than one   * < 13 years           1
  facial     * 13-19 years          0.749     0.133-4.208    0.742
  bone       * 20-29 years          1.035     0.218-4.925    0.965
             * 30 years or older    4.532     1.018-20.186   0.047

OR: odds ratio. 95% CI: 95% confidence interval.
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Title Annotation:Edidemiology
Author:Batist, Anne Margareth; Ferreira, Fernanda de Oliveira; Marques, Leandro Silva; Ramos-Jorge, Maria L
Publication:Brazilian Oral Research
Date:Mar 1, 2012
Words:3665
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