Retrospective Study of Oral and Maxillofacial Trauma in Portuguese Population

Abstract

Objective

The increasing significance of medicolegal evaluation following maxillofacial traumatic events constitutes a complex issue. This clinical research aimed to assess the current etiology of oral and maxillofacial injuries in Portuguese population.

Material and methods

An epidemiological clinical observational study was conducted in Centro Hospitalar Lisboa Norte on a sample of 384 subjects diagnosed with oral and maxillofacial trauma, between 2018 and 2020. Data were collected through clinical reports and analyzed using SPSS version 27.

Results

Women and men were nearly identical in the number and distribution, with 49.5% females and 50.5% males. In 2020, there was a decrease in the number of traumatic incidents compared to other years. Falls or accidental descents were found to be the most common cause of injury, accounting for 44.3%, followed by assaults accounting for 24.7%. A total of 84 subjects exhibited soft tissue injuries related to periodontal region. The upper central incisors (174) were the most frequently affected teeth with uncomplicated fractures, and the predominant form of treatment was the administration of pain medication.

Conclusion

A correlation between falls or accidental descents, female subjects, and advancing age, as well as between assaults, male subjects, and adults, has been established. Falls or accidental descents and assault were the predominant etiologies, and the year 2020 exhibited a decrease in the incidents of traumatic events.

Introduction

The human organism encompasses four key dimensions: functional, biological, psychological, and social. Any disruption to any one of these dimensions can result in bodily harm, which encompasses any injury or sequel present in an individual caused by a disease, psychological disturbance, or traumatic event (1).

There are various forms of traumatic events, with the physical injuries being the most prevalent, thereby constituting a significant global health issue. Upon occurrence of a traumatic event, an individual may experience full recovery from the injury, a temporary impairment, or a sequel, which manifests a permanent psychophysiological alteration resulting from the traumatic experience (2-11).

These injuries can manifest in various parts of the body. However, the present focus will be on oral and maxillofacial injuries which comprise any harm to the region of the oral cavity, including the teeth, tongue, mucosa, mandible, maxilla, zygomatic bones, vessels, nerves, temporomandibular joint, and the soft tissues that line the face.

Oral and maxillofacial injuries represent a significant proportion of medical emergencies, amounting to 7.4 to 8.7% in both developed and developing countries (12, 13). The causes of such injuries vary from country to country. They are influenced by cultural, socioeconomic, and environmental factors (4, 9, 14-27), with the principal etiologies being traffic accidents, falls or accidental descents, and assault.

Treating these traumatic events is a quite complex task. Estetic aspects are not the only aspects requiring consideration, but also the functional aspects of the affected structures, as well as the psychological impact that arises from traumatic experiences (4-6, 8, 15, 19, 24, 28-31).

The goal of the present observational retrospective clinical study was to discuss Portuguese epidemiological data regarding oral and maxillofacial trauma, in the trauma context. In addition, the aim was to assess the follow-up data between injury and sequelae, namely its associations according to etiology and types of oral and maxillofacial injuries. This is important considering that the importance of medicolegal evaluation after traumatic events has been increasing over the years and is a complex issue, mainly in the field of Forensic Odontology for a personal damage assessment.

Material and methods

To achieve the objectives of the research, a retrospective observational study was conducted in the Stomatology Service at the “Centro Hospitalar Lisboa Norte” (CHLN). The study sample comprised individuals aged 21 years or older who sustained oral and maxillofacial injuries between 2018 and 2020. The data collected from the CHLN database were analyzed according to guidelines of the STROBE recommendations.

The study has received ethical approval from the CHLN Ethics Committee, and due to its retrospective design, was exempt from written consent by the IRB of University of Lisbon and conducted in accordance with the Helsinki Declaration of October 2013.

The medical records of all patients were thoroughly reviewed, and the collected data were pseudonymized and recorded in Excel. The extracted information from each patient’s records included demographics such as sex and age, date of injury, etiology, type of injury, location of trauma, type of treatment received, treatment duration, discharge date, duration of hospital stays, date of healing/consolidation, and any sequelae.

The location of trauma was divided into various parts of the oral and maxillofacial region, including gums, alveolar bone, teeth, tongue, buccal mucosa, upper and lower lip, vestibule, maxilla, maxillary sinus, mandible, nasal bone, Le Fort, zygomatic arch, orbital surface, temporomandibular joint, and soft tissues. Mandibular fractures were additionally classified based on their anatomical location into various categories including body, angle, ramus, symphysis, condyle, and coronoid.

The collected data were processed using the Statistical Package for the Social Sciences (SPSS), version 27. Descriptive and inferential statistical analysis was conducted to meet the requirements of the study.

Hypothesis testing was carried out utilizing binomial and chi-square tests, and Clopper-Pearson 95% confidence intervals (95% CI), and contingency coefficients were calculated to validate the findings.

Results

Demographic distribution

A total of 384 patients were analyzed, with 190 females (49.48%) and 194 males (50.52%). The distribution of patients with oral and maxillofacial traumas over the years 2018, 2019, and 2020 is presented in Table 1. It can be observed that the highest number of patients was recorded in 2019, and the lowest in 2020.

Table 1. Sample distribution according to age and year in which trauma occurred.

Year/Age	21-29	30-39	40-49	50-59	60-69	70-79	80-89	90-93	Total
2018	35	26	19	13	20	8	6	1	128
2019	37	43	42	11	21	13	8	0	175
2020	27	16	17	6	9	4	2	0	81
Total	99	85	78	30	50	25	16	1	384

Most frequently affected age group was individuals between the ages of 21 to 29. A higher prevalence of male individuals was observed in the age group between 21 and 49, whereas a higher prevalence of female individuals was noted in the age group between 50 and 93. Statistical analysis revealed a significant association between age and sex, as indicated by p-value <0.001, and a contingency coefficient CC= 0.305.

Etiology

Accidental fall was the primary cause of maxillofacial injuries, accounting for 44.3% (170 patients) of all cases. Assault was the second most common cause accounting for 24.7% (95 patients) of the cases. As shown in Figure 1, falls are more prevalent among female patients (60.4%), while male patients are more likely to sustain injuries from assault (33.5%). The incidents of sports- and work- related accidents decreased in 2020. The probability of sustaining a fall was estimated to be between 39.9% and 50.1% (95% CI), while the probability of sustaining an injury from assault was estimated to be between 20.8% and 29.8% (95% CI).

Figure 1.

Causes of maxillofacial fractures in 270 patients. n = number of patients

A statistical association between etiology and sex was established (p-value <0.001 e CC=0.335), with female patients being more likely to sustain a fall (53% - 67.5%) and male patients being more likely to sustain an injury from assaults (26.9% to 40.7%), (95% CI).

It has been established that there is a relationship between the cause of maxillofacial injuries and age (p-value <0.001; CC=0.526), with younger individuals being more susceptible to assaults, while falls become more prevalent as age increases. However, no statistical correlation has been found between the cause of maxillofacial injuries and the year in which the accident occurred.

Types and sites of trauma

The classification of maxillofacial injuries was made based on various factors such as skin, bone, dental, periodontal, neurological, and the combinations between these factors. The predominant form of injury was found to be a combination of skin and periodontal injury, affecting 84 patients (21.9%), which was followed by skin injuries alone, affecting 68 patients (17.7%). A statistical analysis revealed no significant correlation between the type of injury and demographic variables such as sex (p-value = 0.36), year of accident (p-value = 0.324) and age (p-value = 0.266). Further analysis revealed that skin injuries combined with periodontal lesions (n=39; n=24), skin injuries (n=32; n=19), where the most frequently observed types of injuries in cases involving falls were skin injuries combined with dental lesions (n=28; n=13).

Out of the 384 patients, 314 were diagnosed sof witht tissues injuries, 57 exhibited bone fractures, 192 had periodontal injuries, 176 sustained dental injuries, and only 5 were found to have neurological injuries.

The most affected sites were the upper central incisors, with 174 injuries recorded at each site, followed by the upper lip with 96 patients and the lower lip with 86. Injuries in the coronoid apophysis, upper left second molar, lower right first molar (teeth 27 and 46, respectively, as per the FDI - World Dental Federation notation), Le Fort I, and Le Fort III were not detected. Figures 2 and 3 provide an illustration of the distribution of the injury sites. The most prevalent injury in the lips was laceration, while swelling and abrasion were frequently observed in the soft tissue injuries. All of the neurological injuries were diagnosed as hypoesthesia.

Figure 2.

Site of dental injuries. Teeth are classified according to FDI - World Dental Federation notation

Figure 3.

Distribution by site of the remaining injuries found in the articles

The mandibular region has been the most frequently affected area (n=20)regarding bone fractures. This distribution is presented in Table 2. As for dental injuries, uncomplicated crown fractures were the predominant type observed in the upper incisors.

Table 2. Distribution of bone fractures.

Site	Bone fracture
Maxilla	4
Maxillary sinus	4
Mandible	2
Mandibular body	5
Mandibular angle	5
Zygomatic arch	3
Nasal bone	16
Orbital surface	4
Le Fort II	1
Mandibular ramus	1
Mandibular condylar process	6
Mandibular symphysis	1

Management of the trauma

Out of 348 patients, 218 underwent surgical treatment, 79 received dental treatment, 210 conservative treatment, and 278 patients received pharmacological treatment.

The most frequent pharmacological treatment was the prescription of pain medication (n=101; 26.8%). Among the surgical treatment, suturing (n=45), wound disinfection with suturing (n=37), and teeth extractions (n=32) were the most frequently performed procedures.

For conservative treatments, splinting (n=51), soft diet (n=47), and a combination of splinting and soft diet (n=30) were the most common forms of treatment. In terms of dental treatments, the most frequently performed procedures were restorations (n=19), pulp protection (n=18), and a combination of restorations and pulp protection (n=21).

Length of hospital stay ranged from 0 days (n=369), 1 day (n=4), 2,4, and 5 days (n=2) and 3,6, and 12 days (n=1). Information on the hospitalization of 2 patients was not available.

Discussion

In 2020, the number of traumatic incidents was comparatively lower due to the impact of the ongoing pandemic situation, with individuals spending more time at home, thus being less exposed to potential traumatic events. This decrease in trauma incidents aligns with the reduced participation in sports activities as a result of mandatory lockdowns (32, 33).

The most prevalent etiology in the current study was identified as falls, which has been supported by previous studies conducted by Mahmoodi et al. (5), Brucoli et al. (34), Toivari et al. (35) and Guo et al. (36). Additionally, the likelihood of such injury etiology in female patients, and with increasing age, has been noted by several authors (34, 36, 45-48).

Several studies conducted in various European countries have revealed a rising trend of assault as the primary cause of oral maxillofacial trauma in recent years, as evidenced by references (20, 33, 37, 45, 47). Conversely, road traffic accidents have been witnessing a decline, as reported in the systematic review by Barbosa et al. (39), which highlights that Portugal has experienced a reduction in road traffic accidents since the implementation of road safety measures in 1994. These findings are in line with the results obtained in the current study. However, the study conducted by Alves La-Salete (40) in Portugal between 2001-2007 provides conflicting results. There are also other studies (3, 10), which confirmed the fact that assult is a primary cause of oral maxillofacial trauma.

The present study concurs with previous research in revealing the oral and maxillofacial traumas caused by assault are more prevalent among male patients and adults, as stated in (5, 35, 36).

With regards to the categorization of injuries, it is important to acknowledge the scarcity of European studies that examine soft tissue and dental injuries, since majority of investigations only concentrate on fractures and their respective treatments. As per findings of Burnham et al. (38), soft tissues injuries are considered to be most ubiquitous, while Guo et al. (36) reported that lips are the most frequent of soft tissue lesions, which aligns with the results of our study. Given the fact that the lips serve as a protective barrier for the teeth, they present a considerable risk of injuries, particularly lacerations (48).

Some researchers stated that the mandible is the primary site of fractures (3, 10, 35, 41, 42), as confirmed by our research. The disparity between the incidence of fractures in the mandible and nasal bone is minimal. The peculiar shape, location, mobility, presence of unerupted third molars, and limited bone support compared to the maxilla are several of the factors that make the mandible susceptible to fracture.

In terms of dental injuries, the upper central incisors are documented as the teeth most frequently affected by fracture (43), with uncomplicated crown fracture being the most widespread (5). This piece of information concurs with the outcomes of our study.

The study by Mahmoodi et al. (5) addresses diverse treatments applied, with an emphasis on the prevalence of restorations as dental treatment, splinting as a conservative treatment, suture as a surgical treatment, and the prescription of antibiotics as a pharmacological treatment.

In terms of the treatment options, our results mirror those obtained. However, there is a discrepancy with regards to the pharmacological treatment, where the prescription of pain medication is more prevalent in our study.

As for the most frequently applied type of treatment, the pharmacological treatment takes the lead, followed by surgical, conservative, and dental treatments. Some authors have also reported that surgical treatments are more commonly performed than conservative ones (20, 46-48).

The disparity between sexes in our study is minimal, with male patients constituting 50.52% and female patients 49.48%, which is in contrast with previous studies in the field which reported the male predominance (10, 20, 34-37, 44).

This discrepancy may be attributed to cultural variations between the populations analyzed in each study, the fact that in Portugal the difference between sexes is not as pronounced, and because the falls, which predominantly affect female patients, were the primary etiology in our study.

It is worth mentioning that the sample used in this study cannot be extrapolated to represent the entire Portuguese population, as it is a convenience sample consisting of patients from the Central Hospital of Lisbon, CHLN.

Conclusions

The significance of this investigation lies in its ability to identify etiological factors and traumatic events that contribute to oro-maxillo-facial injury evaluation.

The study found that falls or accidental descents were the most frequent causes of maxillofacial traumatic events, followed by assault. The incidence of road traffic accidents has been declining over the years, likely due to stringent road safety regulations. It was noted that male patients and adults were more commonly affected by assaults, whereas falls were more prevalent among females and elderly individuals.

The year 2020 shows a noticeable decrease in the number of injuries, which can be attributed to the pandemic situation.

The research revealed that soft tissues injuries were described as the primary type of injuries and fractures were primarily observed in the mandible and nasal bone. As for dental injuries, the upper central and lateral incisors were frequently impacted by uncomplicated crown fractures. The most commonly employed therapy was the prescription of painkillers, followed by surgical treatment.