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Revista do Colégio Brasileiro de Cirurgiões

Print version ISSN 0100-6991On-line version ISSN 1809-4546

Rev. Col. Bras. Cir. vol.44 no.5 Rio de Janeiro Sept./Oct. 2017

http://dx.doi.org/10.1590/0100-69912017005011 

Original Article

Epidemiological study of facial fractures at the Oral and Maxillofacial Surgery Service, Santa Casa de Misericordia Hospital Complex, Porto Alegre - RS - Brazil

Rodrigo Andrighetti Zamboni1  2 

João Carlos Birnfeld Wagner1 

Maurício Roth Volkweis1 

Eduardo Luis Gerhardt1 

Elissa Muller Buchmann2 

Caren Serra Bavaresco2 

1 - Santa Casa de Misericórdia Complex of Porto Alegre, Bucomaxillofacial Surgery Service, Porto Alegre, RS, Brazil.

2 - Lutheran University of Brazil, Post-Graduation Program in Dentistry, Canoas, RS, Brazil.

ABSTRACT

Objectives:

to investigate the incidence and etiology of face trauma with diagnosis of facial fracture treated at the Buccomaxillofacial Surgery and Traumatology Service of the Santa Casa de Misericórdia Hospital Complex in Porto Alegre.

Methods:

we conducted a cross-sectional, retrospective epidemiological study of 134 trauma victims with 153 facial fractures.

Results:

the male gender was the most affected (86.6%) and the incidence was higher in the age group from 21 to 30 years. The main etiology was assault (38.8%), followed by motor vehicle accidents (14.2%), motorcycle accidents (13.4%), falls (9%), road accidents (6.7%), sports accidents (5.2%), work accidents (5.2%), firearm injuries (4.5%) and cycling accidents (3%). The most frequent fractures were those of the zygomatic complex (44.5%), followed by fractures of the mandible (42.5%), maxillary bone (5.2%), nasal bones (4.5%) and zygomatic arch (3.3%).

Conclusion:

the fractures of the zygomatic complex and the mandible were the ones with the highest incidence in the facial traumas, having physical assaults as their main cause.

Keywords: Epidemiology; Facial Injuries; Oral and Maxillofacial Surgeons

INTRODUCTION

Trauma is the public health problem with the greatest potential to be prevented and treated. Thus, understanding the cause and severity of maxillofacial lesions may contribute to the establishment of clinical and research priorities for the effective treatment and prevention of these injuries1. Trauma is among the leading causes of death and morbidity in the world, accounting for 7.4% to 8.7% of emergency care2. The increase in the level of life expectancy, urban growth and its forms of locomotion, unemployment crises and the consumption of alcohol and drugs in the different regions, alter the age, gender, etiology and frequency of facial lesions3.

Studies aimed at investigating the treatments and complications of facial trauma allow quantification and qualification of such lesions’ sequelae4. The main causes of facial fractures include auto accidents and assaults. Other causes are falls, sports accidents and accidents at work5-7. In some countries, the reduction of motor vehicle accidents by the introduction of safety measures and legislation to punish vehicle-driving irregularities has increased physical assaults and sports accidents to the condition of main agents causing traumatic buccomaxillofacial injuries8. Thus, it is evident the need for campaigns to prevent the main etiological agents of facial trauma, to contribute to the reduction of this type of occurrence.

The objective of this study is to determine the incidence and etiology of facial traumas with diagnosis of facial fractures seen at the Buccomaxillofacial Surgery and Traumatology Service (CTBMF) of the Holy Home of Mercy Hospital Complex of Porto Alegre, RS, Brazil.

METHODS

This work was accomplished after approval by the Ethics in Research Committee of the Holy Home of Mercy of Porto Alegre, under the protocol n° 460/09. This is a retrospective, cross-sectional, epidemiological study of 134 patients with 153 facial fractures treated from January 2004 to December 2008. The data evaluated considered the etiological agent of the lesion, age and gender, as well as the fractures’ locations.

We divided the etiological agents into nine groups: aggression, fall, automobile accidents, cycling accidents, motorcycle accidents, sports accidents, work accidents, firearm injuries and run-overs.

We classified fractures of the facial skeleton into mandibular bone, zygomatic complex, maxillary bones, nasal bones and zygomatic arches9,10. We included orbital fractures in the subgroup of fractures of the zygomatic complex, as it participates in the orbit floor, as well as in its lateral wall11. We included dento-alveolar fractures in the group of fractures of the bone corresponding to the fractured arch, and we excluded the exclusively dental fractures from the statistics.

We analyzed the data collected in the medical charts and transposed them to specific records, being one record for each chart. We extracted the following data: patient identification, age group, gender, etiological agent of facial fracture and facial fracture classification. We performed a descriptive analysis of the data, calculating frequency and percentage for categorical variables, and mean and standard deviation for quantitative variables. To identify the factors associated with the trauma site, we used the ANOVA test with Tukey’s multiple comparisons for the quantitative variables and the chi-square or Fisher’s exact test for categorical variables. We analyzed data in the SPSS 12.0 software and the minimum level of significance was 5%.

RESULTS

Regarding the profile of the patients treated, the male gender was the most affected, representing 86.6% of face fractures, when compared with the female one (13.4%), establishing a ratio of approximately 6:1. Regarding the distribution of frequencies and percentages referring to the age groups, we verified that the most affected age group was from 21 to 30 years old, with 41 cases (30.6%), followed by the age group from 31 to 40 years, with 38 patients (28.4%).

Regarding the etiological agents, we recorded 52 cases (38.8%) of assault, 19 cases of auto accident (14.2%), 18 motorcycle accidents (13.4%), 12 cases of fall (9%), nine run-overs (6.7%), seven sports accidents (5.2%), seven work accidents (5.2%), six cases of firearm injury (4.5%) and four cases of cycling accident (3%) (Table 1).

Table 1  Frequency and percentage of facial fractures according to etiological agent . 

Etiologic Agent Frequency %
Automobile accident 19 14.2
Bicycle accident 4 3.0
Sports accident 7 5.2
Motorcycle accident 18 13.4
Work accident 7 5.2
Assault 52 38.8
Run-over 9 6.7
Firearm 6 4.5
Fall 12 9.0
Total 134 100

Fonte: dados obtidos nos prontuários do Serviço de CTBMF Santa Casa - POA, 2009.

In the distribution of patients with facial fractures according to the etiological agent and in relation to the mean age, we verified, through the Analysis of Variance complemented by the Tukey’s Multiple Comparison Test, that patients with face fractures due to sports accidents were younger (24.86 years) than patients who had face fractures due to work accidents (47 years) or fall. The other etiologies did not differ as for the age (Table 2). We grouped automobile accidents, motorcycle accidents, cycling accidents and run-overs in the item traffic accidents.

Table 2  Distribution of patients with facial fractures according to etiological agents and mean age . 

Etiologic Agent Age group (years)
N Average Standard Deviation
Traffic accident 50 32.08 14.042
Sports accident 7 24.86 5.872
Work accident 7 47.00 11.240
Assault 52 34.56 11.823
Firearm 6 29.00 5.831
Fall 12 42.33 13.547
Total 134 34.22 13.119

Fonte: dados obtidos nos prontuários do Serviço de CTBMF Santa Casa - POA, 2009.

Of the 153 facial fractures, 68 (44.5%) occurred in the zygomatic complex, 65 (42.5%) in the mandible, eight (5.2%) in the maxillary bone, seven (4.5%) in the nasal bones and in the zygomatic arch we recorded five fractures (3.3%) (Table 3). Regarding the number of facial fractures in both males and females, the mandibular bone was the most affected. None of the types of facial fractures assessed in this study showed gender preference, according to the chi-square and Fisher’s exact tests.

Table 3 Distribution of frequencies and percentages of facial fractures . 

Type of fracture Frequency %
Zygomatic Complex 68 44.5
Mandible 65 42.5
Maxilla 8 5.2
Nasal Bones 7 4.5
Zygomatic Arch 5 3.3

Fonte: dados obtidos nos prontuários do Serviço de CTBMF Santa Casa - POA, 2009.

Table 4 shows the distribution of facial fractures according to age group. We found no significant difference in this assessment.

Table 4  Distribution of facial fractures according to age group. 

Type of fracture Age (in years)
11-20 21-30 31-40 41-50 51-60 61-70 Total
Zygomatic Complex 9 16 19 11 9 4 68
Mandible 8 23 21 8 2 3 65
Maxilla 0 1 3 1 2 1 8
Nasal Bones 3 2 1 1 0 0 7
Zygomatic Arch 0 1 3 0 1 0 5

Fonte: dados obtidos nos prontuários do Serviço de CTBMF Santa Casa - POA, 2009.

With respect to the frequency and percentage of the etiological agent related to the facial fracture region, the Fisher’s exact test showed no significant difference in fracture type according to etiology. Regarding gender and etiological agent, we observed that men presented more fractures due to assaults (42.2%), while women had more fractures due to run-overs (22.2%) and falls (27.8%).

DISCUSSION

The results of an epidemiological survey of face traumas of a population should be evaluated according to a series of variables related to individuals and the region studied. Ellis et al.12 point out that the cause of the lesion and the geographical area where it occurred, the socioeconomic level of the population, the study period and the population mobility can alter results and show the most varied trauma presentations. Data obtained in this study revealed that the two main etiological factors of facial fractures are assaults and traffic accidents. Three decades ago, the studies pointed to motor vehicle accidents as the main cause of facial trauma9,10. However, current research in Brazil shows an increasing participation of physical assault as an etiological factor of facial trauma due to the increase in urban violence, which, among other problems, is associated with the socioeconomic and emotional conflicts to which many individuals are subjected, especially the youngest6,11.

Public actions such as speeding control and severe punishment for drunk drivers, as well as the introduction of safety devices such as seat belts and helmets, air bags, side protection bars and the evolution of the automobile industry as a whole are responsible for decreasing the number of facial traumas due to motor vehicle accidents10,13. Our results are in agreement with other evidence in the literature reporting that assaults were the main cause of facial fractures3,11,14-19. In the present study, assaults resulted in 38.8% of the cases, excluding gunshot wounds.

The second most involved etiological agent was automobile accidents, accounting for 14.2% of facial fractures, being in accordance with the literature. When studied in conjunction with run-overs, motorcycle accidents and cycling accidents, that percentage rises to 37.3%. These data show a worrying reality, since even when all types of traffic accidents were present, the facial trauma index was still lower than that of assaults16. Other studies, however, still point car accidents as the most frequent etiological agent3,20-23. This may be due to the inclusion of patients who were victims of facial trauma in the eighties and nineties, when the use of protective equipment in vehicles was not mandatory, especially in Brazil10,13.

According to Adebayo et al.5, the etiologies of face traumas vary with the socioeconomic conditions of each region. Studies carried out in different regions report divergences regarding the main etiological factor. Thus, Thomson et al.23 verified that most facial fractures were caused by falls and Subhashraj, Ramkumar and Ravindran24 concluded that the motorcycle accident was the main etiological factor. In our study, these agents represented the fourth and third causes of facial fracture, respectively.

Accidents at work were the etiological agent with the highest mean age (47 years), while sports accidents had the lowest one (24.86 years). Fall is the main mechanism of trauma in the age group over 40 years, and is usually related to the presence of multiple diseases9,19,25. However, Macedo et al.11 stated that the fall proved to be an important trauma mechanism at the extremes of age. Karyouti26 reported that children are constantly engaged in sports activities and risky exercise, without the use of appropriate protective equipment and away from the supervision of those responsible, contributing to the increase in the number of facial fractures. Since the care for children in the facility where we conducted this study is restricted, we could not confront these data6,27.

Regarding age, the studied sample revealed that the highest prevalence of facial fractures occurs in the age group of 21 to 30 years and from 31 to 40 years, unlike other studies in which the predominant age group was from 61 to 70 years old5,9,15,17,20-23,28-34. For Reis et al.14, the most affected age group was 11 to 30 years. This is due to the fact that in this age group individuals are more exposed to the risk factors, since they are in full physical and professional activity7. Evidence in the literature reveals a high number of fractures and facial trauma caused by sports, among them soccer, hockey, rugby and wrestling, which brings into question the incentive to use personal protective equipment7.

Fractures of the zygomatic complex were responsible for 44.5% of the total fractures in this study, followed by mandible fractures, with 42.5%, both in agreement with the reviewed literature5,20,21-23,26,28,30,31,34. However, there is great disagreement with the researched authors, the nose bone fractures being more prevalent in several studies17,29,32. As for Alvi, Doherty and Lewen16, orbital fractures were the most prevalent.

The relationship between the type of fracture and the etiology of trauma showed no difference in this study. Some works have found that most mandible fractures are the result of physical assault, traffic accidents, gunshot wounds, accidents with industrial workers and sports accidents7,19. According to Greenberg and Haug25, assaults cause more fractures of the mandible, zygomatic complex and nose bones, whereas motor vehicle accidents promote more fractures in the maxillary bones.

As in most studies, our work showed a predominance of facial fractures in men5,9,11,15,20,34. Thomson et al.23, however, identified the female gender as more prevalent. We observed a difference in etiology according to gender, in which men have more fractures due to assaults (42.2%), while women have more fractures due to run-overs (22.2%) and falls (27.8%).

Silva34 emphasizes that trauma should not be seen only as a medical problem, but also a social and economic one. Costs incurred in providing care to victims by health workers, damage to property involved at the time of trauma, loss of wages and permanent or transient disabilities often lead to difficulties in the social reintegration of victims and their return to the job market. All these factors, added to the familiar inconveniences and psychological wear and tear on patient care reveal a much greater repercussion of this disease, which deserves constant attention by health institutions that provide assistance to traumatized patients.

This research provides data for a better understanding of the facial fractures’ main etiological agents and the most affected bones in the studied population, being of fundamental importance for the planning, organization and improvement of care of such patients.

REFERENCES

1 Gassner R, Tuli T, Hächl O, Moreira R, Ulmer H. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg. 2004;62(4):399-407. [ Links ]

2 Barker R, Hockey R, Spinks D, Miles E. Facial Injury. Injury Bulletin Queensland Injury Surveillance Unit. 2003;79:1-6 [ Links ]

3 Banks P. Killey's fraturas da mandíbula. 4ª ed. São Paulo: Santos; 1994. [ Links ]

4 Moreira RWF. Análise epidemiológica de casos de traumatismo crâniomaxilo-facial atendidos no Estado da Pensilvânia - EUA, no período entre 1994 e 2002 [dissertação]. Piracicaba (SP): UNICAMP/FOP; 2004. [ Links ]

5 Adebayo ET, Ajike OS, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br. J. Oral Maxillofac. Surg. 2003;41(6):396-400. [ Links ]

6 Owusu JA, Bellile E, Moyer JS, Sidman JD. Patterns of Pediatric Mandible Fractures in the United States. JAMA Facial Plast Surg. 2016;18(1):37-41. [ Links ]

7 Bobian MR, Hanba CJ, Svider PF, Hojjat H, Folbe AJ, Eloy JA, et al. Soccer-related facial trauma. A nationwide perspective. Ann Otol Rhinol Laryngol. 2016;125(12):992-6. [ Links ]

8 Holderbaum MA. Levantamento epidemiológico das fraturas de face na comunidade atendida junto ao Grupo Hospitalar Conceição - Porto Alegre, 1997 [dissertação]. Porto Alegre (RS): Pontifícia Universidade Católica do Rio Grande do Sul; 1997. [ Links ]

9 Wulkan M, Parreira Júnior JG, Botter DA. Epidemiologia do trauma facial. Rev Assoc Med Bras. 2005;51(5):290-5. [ Links ]

10 Montovani JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiologia e incidência das fraturas faciais em adultos e crianças: experiência em 513 casos. Rev Bras Otorrinolaringol. 2006; 72(2):235-41. [ Links ]

11 Macedo JLS, Camargo LM, Almeida PF, Rosa SC. Perfil epidemiológico do trauma de face dos pacientes atendidos no pronto socorro de um hospital público. Rev Col Bras Cir. 2008;35(1):9-13. [ Links ]

12 Ellis E 3rd, el-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital fractures. J Oral Maxillofac Surg. 1985;43(6):417-28. [ Links ]

13 Shapiro AJ, Johnson RM, Miller SF, McCarthy MC. Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse. Injury. 2001;32(5):353-6. [ Links ]

14 Reis LF, Marzola C, Toledo Filho JL. Prevalência das fraturas faciais, na região de Bauru, no período de janeiro de 1991 a dezembro de 1995. Rev Odonto Ciênc. 2001;16(34):231-40. [ Links ]

15 Valente ROH, Souza LCM, Antonini SV, Glock L, Castro Neto WN. Epidemiologia das fraturas mandibulares atendidas no Hospital da Santa Casa de Misericórdia de São Paulo (HSCSP) entre 1996 e 1998. Rev Bras Cir Period. 2003;1(2):141-6. [ Links ]

16 Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope. 2003;113(1):102-6. [ Links ]

17 Portolan M, Torriani MA. Estudo de prevalência das fraturas bucomaxilofaciais na região de Pelotas. Revista Odonto Ciênc. 2005; 20(47):63-8. [ Links ]

18 Falcão MFL, Segundo AVL, Silveira MMF. Estudo epidemiológico de 1758 fraturas faciais tratadas no Hospital da Restauração, Recife/PE. Rev Cir Traumatol Buco-Maxilo-Fac. 2005;5(3):65-72. [ Links ]

19 Moore BK, Smit R, Colquhoun A, Thompson WM. Maxillofacial fractures at Waikato Hospital, New Zealand: 2004 to 2013. N Z Med J. 2015;128(1426):96-102. [ Links ]

20 Brasileiro BF. Prevalência, tratamento e complicações dos casos de trauma facial atendidos pela FOP - UNICAMP de abril de 1999 a março de 2004 [dissertação]. Piracicaba (SP): UNICAMP; 2005. [ Links ]

21 Patrocínio LG, Patrocínio JA, Borba BHC, Bonatti BS, Pinto LF, Vieira JV, et al. Fratura de mandíbula: análise de 293 pacientes tratados no Hospital de Clínicas da Universidade Federal de Uberlândia. Rev Bras Otorrinolaringol. 2005;71(5):560-5. [ Links ]

22 Paes JV. Estudo retrospectivo da prevalência de fraturas de faciais no planalto serrano Catarinense. [dissertação] Porto Alegre (RS): Pontifícia Universidade Católica do Rio Grande do Sul; 2008. [ Links ]

23 Thomson WM, Stephenson S, Kieser JA, Langley JD. Dental and maxillofacial injuries among older New Zealanders during the 1990s. Int J Oral Maxillofac Surg. 2003;32(2):201-5. [ Links ]

24 Subhashraj K, Ramkumar S, Ravindran C. Pattern of mandibular fractures in Chennai, India. Br J Oral Maxillofac Surg. 2008;46(2):126-7. [ Links ]

25 Greenberg AM, Haug RH, editors. Craniomaxillofacial fractures: principles of internal fixation using the AO/ASIF technique. New York: Springer-Verlag; 1993. [ Links ]

26 Karyouti SM. Maxillofacial injuries at Jordan University Hospital. Int J Oral Maxillofacial Surg. 1987;16(3):262-5. [ Links ]

27 Almahdi HM, Higzi MA. Maxillofacial fractures among Sudanese children at Khartoum Dental Teaching Hospital. BMC Res Notes. 2016;9:120. [ Links ]

28 Camarini ET, Pavan AJ, Iwaki Filho L, Barbosa CEB. Estudo epidemiológico dos traumatismos bucomaxilofaciais na região metropolitana de Maringá-PR entre os anos de 1997 e 2003. Rev Cir Traumatol Buco-Maxilo-Fac. 2004;4(2):125-9. [ Links ]

29 Mourouzis C, Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg. 2005;34(6): 635-8. [ Links ]

30 Bezerra MF. Estudo epidemiológico dos pacientes hospitalizados e atendidos pelo Serviço de Cirurgia e Traumatologia Bucomaxilofacial do Hospital São Lucas, Porto Alegre, 2000 a 2005 [dissertação]. Porto Alegre (RS): Pontifícia Universidade Católica do Rio Grande do Sul; 2006. [ Links ]

31 Menezes MM, Yui KCK, Araujo MAM, Valera MC. Prevalência de traumatismos maxilo-faciais e dentais em pacientes atendidos no Pronto-Socorro Municipal de São José dos Campos/SP. Revista Odonto Ciênc. 2007;22(57):210-6. [ Links ]

32 Sarmento DJS, Santos JA, Cavalcanti AL. Características e distribuição das fraturas mandibulares por causas externas: estudo retrospectivo. Pesq Bras Odontoped Clin Integr. 2007;7(2):139-44. [ Links ]

33 Claro FA. Prevalência de fraturas maxilo-faciais na cidade de Taubaté: revisão de 125 casos. Rev Biociênc Taubaté. 2003;9(4):31-7. [ Links ]

34 Silva AC. Análise epidemiológica e avaliação do tratamento e das complicações dos casos de trauma facial atendidos na FOP - Unicamp, no período de abril de 1999 a março de 2000 [dissertação]. Piracicaba (SP): UNICAMP; 2001. [ Links ]

Source of funding: none.

Received: April 28, 2017; Accepted: June 22, 2017

Mailing address: Caren Serra Bavaresco E-mail: c_bavaresco@yahoo.com.br/ tutoracarensb@gmail.com

Conflict of interest:

none.

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