Introduction

The occurrence and causes of maxillofacial trauma vary in different regions of the world. It seems that that some socio-economical, educational, cultural and environmental differences, as well as traffic regulations and alcohol consumption influence the incidence of the injuries (1-4).

Severe facial lesions occur very often due to little protection and significant exposure of the facial region, and according to MacKenzie’s research account for almost 50% of all traumatic deaths (5).

The results of different studies have shown the significant difference in maxillofacial trauma causes dependant on the level of development of different countries.

According to the results of research in developed countries, assault is the first leading cause of this type of injuries, followed mostly by automobile accidents, pedestrian collisions, sports and industrial accidents (6-11).

On the other hand, the leading causes of maxillofacial trauma in underdeveloped countries are road traffic accidents, followed by assaults and warfare (12-17).

It also seems that different types of injuries, such as maxillary and mandible bone fractures, soft tissue lesions, dental trauma and combinations of the above mentioned occur in certain situations (6, 18, 19).

Gassner et al. reported 25% of bone fractures and 58% of soft tissue lesions in patients involved in traffic accidents and 49% of dental trauma during activities of daily life and play accidents (6).

The aim of this study was to identify the occurrence, types and causes of maxillofacial injuries according to the age and gender differences in patients treated at Department of Maxillofacial Surgery, University Hospital Osijek between January 2011 and December 2013. The null hypothesis of this study was that there are no differences in types and causes of the maxillofacial injuries in different age and gender groups of patients.

Materials and methods

A total of 83 patients with maxillofacial injuries were diagnosed and treated at Department of Maxillofacial Surgery in Osijek between January 2011 and December 2013.

The criteria for the inclusion in the study were the absence of any signs of concomitant injuries of other body parts as well as the patient’s Glasgow coma score 15 (eye opening, verbal and motor response) (20). Since there were 15 patients with the injuries of arms and legs too and 4 patients received Glasgow coma score 13, they were excluded from the study. Isolated nose injuries were also excluded from the study.

Finally, 64 patients, 41 males (64.1%) and 23 females (35.9%), aged from 18 to 86 years (mean age 42) participated in the study. None of the patients reported alcohol consumption prior to the injury.

In this study maxillofacial injuries were diagnosed after a detailed clinical and radiological examination. The traumatic injuries associated with the facial region were classified as soft-tissue injury, bone injury, soft-tissue and bone injury, soft-tissue and dentoalveolar injury and combined injury (soft-tissue, bone and dentoalveolar injury).

The patients also reported the cause of the maxillofacial injury as violence, traffic or sports accident, an injury which occurred during recreation activities or work accident.

Data were imported into statistical program SPSS 19.0 (SPSS, Chicago, IL, USA). To estimate the difference in types and causes of the maxillofacial injuries according to the different age and gender parameters, the x² test was used.

Results

A total of 64 patients with different types of maxillofacial trauma were treated at Department of Maxillofacial Surgery, University Hospital Center Osijek between January 2011 and December 2013.

There were 41 males (64.1%) and 23 females (35.9%), giving a male to female ratio of 2.78:1.

Distribution of patients according to gender and causes of injuries is shown in Figure 1. The most common reported cause of injuries in both gender groups was falling down (39% males; 65% females). The second leading cause of injuries in males was interpersonal violence (29%), followed by sports accidents (12%) and recreation (10%). The same percent of patients reported the injuries were caused in traffic or at work (5% respectively) (Figure 1). In female group the second leading cause of injuries was traffic accident (26%), followed by violence and sports accidents (4% respectively). None of the female patients reported their injuries were caused in recreation or at work (Figure 1). The gender difference in injury causes was found to be statistically significant (X²=16.22; df=5; p=0.006).

Figure 1 Distribution of patients according to gender and causes of injuries

Distribution of patients according to gender and types of injuries is shown in Figure 2. The most common reported type of injury in both gender groups was bone injury (51% males; 52% females). In males the most frequent fracture was zygomatic bones 55%, followed by mandible 20% and maxilla 17%. In females the most frequent fracture was mandible 40%, followed by zygomatic bones 36% and maxilla 7%. The second leading cause of injuries in males was soft-tissue injury (24%), followed by soft-tissue and bone injury (17%) combined injury (5%) and soft-tissue and dentoalveolar injury (3%) (Figure 2).

Figure 2 Distribution of patients according to gender and types of injuries

The second leading type of injuries in females was soft-tissue injury (30%), followed by soft-tissue and dentoalveoar injury (9%), and soft-tissue and bone injury as well as combined injury (4,5% respectively) (Figure 2). The gender difference in types of injuries was not statistically significant (p>0.05).

The patients in this study were 18 to 86 years old. The patients up to 28 years old were considered the first age group (21; 33%), from 28 to 50 the second (20; 31%) and more than 50 years old the third age group (23; 36%).

Distribution of patients according to the age group and causes of injuries is shown in Figure 3.

Figure 3 Distribution of patients according to age group and causes of injuries

The most common causes of injuries in the youngest patients were violence (43%), followed by fall (24%) and recreation, traffic and work accidents (10% respectively) (Figure 3). Only 3% of the youngest patients reported the injuries caused by sports activity (Figure 3). In the middle-aged group the most common cause of injuries was falling down (50%), followed by violence, traffic and sports accidents (15% respectively) and recreation (5%). None of the patients in the middle-aged group reported injuries caused at work (Figure 3). In the oldest age group, the most common cause of injuries was falling down (70%), followed by traffic (13%) and sports accidents (9%) and violence and recreation (4% respectively). In this age group, none of the patients reported the injuries caused at work as well (Figure 3). The age difference in injury causes was found statistically significant (X²=19.23; df=10; p=0.037).

Distribution of patients according to the age group and types of injuries is shown in Figure 4.

Figure 4 Distribution of patients according to age groups and types of injuries

The most common reported type of injury in all age groups was bone injury (48% first; 50% second; 57% third age group). The second leading cause of injuries in all age groups was soft-tissue injury (29% first; 25% second; 26% third age group), followed by soft-tissue and bone injury (14% first; 10% second; 13% third age group). Less than 5% of the injuries were soft-tissue and dentoalveolar injury or combined (5% respectively) (Figure 4). The age difference in types of injuries was not statistically significant (p>0.05).

The majority of the falls and violence caused bone tissue injuries, and soft tissue and dentalveolar injuries were detected in traffic and sports accidents (Figure 5; p>0.05).

Figure 5 Distribution of different types of injuries according to the causes

Discussion

There are great variations in epidemiological features of maxillofacial injuries among population of different regions of the world, and sometimes even within the same country (8, 21, 22).

The results of this study showed that maxillofacial injuries are more common in males, with a male to female ratio of 2.78:1. This ratio seems to vary in different regions, from 1.3:1 in province of Pescara in Italy, 2:1 in Austria, 2.8:1 in Turkey and Japan, up to 4.6:1 in Southern Bulgaria and Middle East countries (6, 10, 13, 18, 23, 24). The reason for the high male to female ratio in some regions of the world may be not only the segregation of women from social life in eastern countries, but also the great number of male vehicle drivers, their practice of more physical contact sports and higher consumption of alcohol and other drugs (18).

Our gender distribution of maxillofacial injuries is more similar to urbanized European countries with the increasing female participation in activities that were previously male dominant (25).

The results concerning causes of maxillofacial injuries generally differ. The majority of the studies prove traffic accidents to be the primary cause of the maxillofacial trauma, followed by interpersonal violence and falls (10, 17, 23, 26). It seems that the problem with road accidents exists in both developed and undeveloped countries, but is interpreted differently.

In undeveloped countries it is obvious that the lack of traffic regulations as well as poor road infrastructure and old vehicles without safety features influence the prevalence of maxillofacial injuries (27, 28). Ramalingam reported even more than 70% of the patients with maxillofacial trauma were injured in road traffic accidents in India in three years (27). On the other hand, in some developed European countries the leading cause of maxillofacial injuries is the same (8, 23, 29). This can be attributed to the violation of speed limits due to the very fast modern vehicles, failure to wear seat belts and helmets and consumption of alcohol or other intoxicating agents (26). In these countries there is also a high increase in two wheelers responsible for the injuries because in urban cities the bicycles and motorcycles are very popular as means of transport (23). It is also interesting that in the developed countries the number of females injured in road traffic accidents is still increasing thus proving that they are involved in social life equally as men (23).

There are still a great number of studies revealing the interpersonal violence as a major cause of maxillofacial injuries. In Arslan’s study the most common cause of the maxillofacial trauma was violence, accounting for 40% of the sample (18). Lee et al. reported almost the same percentage, but in Bakardjiev’s study it was 61% of the sample (12, 13). It is also important to mention that in all studies where the leading cause of the maxillofacial injuries was some kind of violence mostly young men were involved (12, 13, 18).

Falling down was usually mentioned as the second or the third cause of oro-maxillofacial injuries, amounting to 20-30% and mostly in elderly patients (18, 23, 26).

The results of this study revealed fall as a major cause of all oro-maxillofacial injuries in men and in women, but violence as the second one in men and traffic accident as the second one in women (Figure 1) (p<0.05). This finding is in accordance with the results of other studies proving that men suffer more violence than women.

Regarding the age of the patients in this study, in the youngest group (up to 28 years old) the leading cause of injuries was violence (12%), but in those older than 28 it was fall (25%), and the results comply with those from other studies (Figure 3; p<0.05). The mean age in our study was 42 (60% of them were older than 28) and the patients were not as young as in some studies. We also had some patients older than 80 years and it was expected that their main cause of injuries was fall.

Therefore, our null hypothesis concerning no difference in types and causes of oro-maxillofacial injuries in different age and gender groups of patients was rejected.

Considering the clinical aspects of oro-maxillofacial trauma, the high rate of bone injuries (mainly mandible and zygomatic bones) in majority of the studies is obviously related to the most prominent position of these anatomical structures as well as the fact that these bones are mainly unprotected because the automobile drivers do not wear helmets and there is a great number of accidental falls where the patients react automatically protecting other parts of the body instead of the head. It also seems that the cause of the oro-maxillofacial trauma is correlated with the type of the injury.

Arslan et al. found 56% of bone fractures in his study and most of them were maxillary bone fractures (30%) caused by violence (40%) assuming that the mid-facial part is the most affected region while fighting (18).

Ascani et al. reported mandible fractures in 31% and zygomatic bone fractures in 22% with the most common cause of the maxillofacial fractures in their study being road traffic accidents, and among them two wheelers participated in 73% (23).

Almost the same percentage of mandible and zygomatic bone fractures were reported in Eidt’s study with car accidents as the main cause of injuries, but he also reported 16% of soft-tissue as well as 2.6% dentoalveolar injuries (26). Gassner et al. also reported a great amount of soft-tissue injuries (62.5%) and 50% of dentoalveolar injuries originating from daily life and sports activities (69%) (6). In Ramli’s study the most common injury was soft-tissue injury too (30).

In our study the most common injury in men and in women was bone injury (zygomatic bones 55%, followed by mandible 20% and maxilla 17%) (Figures 2 and 5; p>0.05). Taking into account that the leading cause of these injuries was falling down, that the mean age in this study was 42 and that we had 15% of them older than 65, we can attribute this finding to the fact that zygomatic bone is usually fractured due to its most exposed head position and first one in contact with the floor during the fall. The next type of trauma in this study in men and women was soft-tissue (24-30%) (Figure 2; p>0.05). Women also had more soft-tissue and dentoalveolar injuries and men more soft and bone tissue injuries (Figure 2; p>0.05).

There is also one very important factor influencing the incidence of maxillofacial trauma. In the study by Ascani et al., almost 40% of the patients reported they had been under the effect of alcohol at the time of injury and these results are in accordance with some other studies (10, 23, 31-33). In our study, none of the patients reported alcohol consuming and we think this was not true. They were probably ashamed to admit it because the middle-age group in the study (from 28 to 50 years old) revealed fall as the major cause of the injuries and they were still not old enough to have neuromuscular and degenerative problems affecting their walking coordination.

The limitation of this study is the small sample which has to be increased as well as to include data about the therapy of different types of the oro-maxillofacial injuries in further studies.

Conclusion

According to the results of this paper, we can conclude that falling down was the most common cause of oro-maxillofacial injuries in both men and women and in all three age groups. The leading types of injuries were bone injuries, mostly zygomatic bones. Preventive measures, such as enforcement of the law regarding drinking as well as the obligatory wearing of a helmet and seat belts may reduce the number of maxillofacial injuries.