Abstract
Background
Maxillofacial injury is a major health concern worldwide. Incidence of maxillofacial fractures is influenced by socio-demographic, economic, and cultural factor of the population investigated. Identifying the patterns of these fractures is crucial to establish effective treatments and prevention measures. The aim of the study was to to analyze the incidence, etiology, and types of maxillofacial fractures in a tertiary trauma center.
Methods
A retrospective analysis was conducted for all patients who were admitted with maxillofacial fractures at King Abdulaziz Medical City, Riyadh, Saudi Arabia. A total of of 422 patients with 978 maxillofacial fractures were enrolled over a 4-year period.
Results
Among the 422 patients, 387 (91.8%) were males, and 35 (8.2%) were females. The mean age of our population was 31.1 years old. Our study has shown that motor vehicle accidents are the leading cause of maxillofacial fractures, followed by pedestrian trauma. The most common maxillofacial fractures were orbital fractures, followed by maxillary fractures. The mandibular body was most fractured among mandibular fractures. Our data has shown that males have higher incidence of maxillofacial fractures than females.
Conclusion
Our study further validated that road traffic accidents are the most common cause of maxillofacial fractures in our region. These findings emphasized the importance of improving road safety protocols and enforcing traffic laws.
Keyword: Maxillofacial trauma
1. Introduction
Traumatic injuries are the leading cause of morbidity and mortality worldwide (Saudi, 2014). The 2010 Global Burden of Disease Study (GBD) shows that injuries caused 11.2% of disability-adjusted life-years (DALYs) worldwide, with RTAs accounting for 27% of these injuries (Murray et al., 2012). Motor vehicle accidents (MVAs) are one of the most prevalent health hazards and can result in devastating morbidities (Murray et al., 2012, Road traffic injuries, n.d.). In Saudi Arabia, road traffic accidents (RTAs) are becoming a serious public health concern. An analysis of RTAs in SA found that road traffic injuries accounted for 83.4% of all trauma admissions, with the head and neck being the most injured body regions (Mansuri et al., 2015). Injuries to the maxillofacial region are common among RTAs, ranging from minor fractures to severe or gross injuries (Jose et al., 2016, Patil et al., 2018, Singaram et al., 2016). Multiple factors affect the incidence and characteristics of maxillofacial fractures, such as sociodemographic, economic, and cultural aspects of the population studied (Mabrouk et al., 2014, Singaram et al., 2016) Prior studies conducted in Saudi Arabia reported motor vehicle accidents as the leading cause of maxillofacial fractures (Al-Bokhamseen et al., 2019, Ali-Alsuliman et al., 2018, Almasri et al., 2015, Samman et al., 2018). In other countries, however, maxillofacial fractures are mostly caused by assaults (Boffano et al., 2015a, Ceallaigh et al., 2006). A variety of patterns of maxillofacial injuries have been reported in literature. Fractures of the mandible were most prevalent in SA (Abdullah et al., 2013, Al-Bokhamseen et al., 2019, Samman et al., 2018). Injury to the maxillofacial region often leads to other systemic injuries resulting in long-term effects, both functionally and aesthetically (Nayak et al., 2021). Several types of concomitant serious injuries were reviewed in the literature, and traumatic brain injuries were the most prevalent associated with traumatic facial injuries (Patil et al., 2018, Scherbaum Eidt et al., 2013). A comprehensive understanding of the trends and severity of maxillofacial injuries is vital for the establishment of effective treatments and prevention measures. Although several studies examined various aspects of maxillofacial trauma in Saudi Arabia, a further addition is needed to obtain a better understating of these fractures. Thus, the aim of this study is to identify the trends and characteristics of maxillofacial fracture in level I and II trauma patients in a tertiary trauma center in Riyadh, Saudi Arabia. In addition, this study determines the incidence of concomitant injuries associated with maxillofacial fractures.
2. Methods
2.1. Study setting and design
This is a retrospective cross-sectional study conducted at King Abdulaziz Medical City (KAMC), Department of Emergency Medicine, Riyadh, Saudi Arabia. This hospital is an advanced trauma center that provides care to the population of the national guard and their dependents as well as non-national guard patients through its medical eligibility system. The bed capacity of KAMC includes 1973 operational beds.
2.2. Data collection
The data used in this study were extracted from the hospital trauma registry and the patients’ electronic files from January 2018 to December 2021. The population of the study included all adult patients, 14 years and older, from all nationalities who were admitted with maxillofacial trauma. Patients who were treated in an outpatient setting, transferred to another hospital, or who announced death upon arrival were excluded. The following data were collected from the patients: demographic variables, initial vital signs, trauma level, Glasgow Coma Scale score, cause of injury, and maxillofacial fracture pattern based on CT imaging and surgery reports. Maxillofacial fractures were classified as frontal, nasal, zygomatic, maxillary, orbital, and alveolar. Patients were also evaluated for the presence of any associated injuries. The associated injuries were categorized into head injuries, abdominal/pelvic injuries, chest injuries, spinal injuries and limb injuries.
2.3. Statistical analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS) (IBM Corp. Released 2021 IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY). Data on categorical variables are reported as frequency and proportion, while data on numerical variables are reported as mean and standard deviation. The chi-square test was used to determine if two categorical variables are associated. A p-value of less than 0.05 was considered significant.
3. Results
3.1. Demographic distribution
The baseline characteristics of patients with maxillofacial fractures are listed in Table 1. Over the study period from January 2018 to December 2021, a total of 422 patients with 978 maxillofacial fractures were recorded and analyzed. Most of the patients were male (n = 387, 91.8%). Mean patient age was 31 (SD ± 13) years. An initial Glasgow Coma Scale of less than 10 was recorded in 204 patients. The rate of death in the emergency department was 1.4% (6 cases). The number of patients who were intoxicated was 7 (1.7%). Nearly-two-thirds (n = 272, 64%) of the patients were intubated in the emergency room. Patients were mostly transferred from the ED to an intensive care unit (n = 208, 49%) or to an operation room (n = 98, 23.2%).
Table 1.
Baseline characteristics of patients with maxillofacial fractures.
| Number | Percentage/SD | ||
|---|---|---|---|
| Gender | Male | 387 | 91.80% |
| Female | 35 | 8.20% | |
| Age | 31 | 13 | |
| GCS | 15 | 122 | 28.90% |
| 14 | 28 | 6.60% | |
| 13 | 24 | 5.70% | |
| 12 | 14 | 3.30% | |
| 11 | 18 | 4.30% | |
| 10 | 12 | 2.80% | |
| 9 | 18 | 4.30% | |
| 8 | 36 | 9% | |
| 7 | 42 | 10.00% | |
| 6 | 26 | 6.20% | |
| 5 | 10 | 2.40% | |
| 4 | 10 | 2.40% | |
| 3 | 62 | 14.70% | |
| Injury mechanism | MVA | 263 | 62.30% |
| Motorcyle accident | 28 | 6.60% | |
| Pedestrian | 69 | 16.40% | |
| Stab wound | 4 | 1% | |
| Gunshot | 3 | 0.70% | |
| Fall | 45 | 10.70% | |
| Blast injuries | 7 | 1.70% | |
| Other | 3 | 0.70% | |
| Intubation | 272 | 64% | |
| Intoxicated | 7 | 1.70% | |
| Disposition from ER | ICU | 208 | 49% |
| OR | 98 | 23.20% | |
| Ward | 76 | 18.00% | |
| Discharge from ER | 34 | 8.10% | |
| Death in the ER | 6 | 1.40% | |
3.2. Patterns of maxillofacial fractures
A detailed distribution of maxillofacial fractures is shown in Table 2 and Table 3. The most common maxillofacial fractures were orbital fractures (n = 203, 20%), followed by maxillary fractures, nasal fractures, frontal fractures, mandibular fractures, zygomatic fractures, and the alveolar bone fractures. For maxillary fractures, Le Fort-1 fractures were the most common (n = 114, 63.33%), followed by Le Fort-2 fractures, and Le Fort-3 fractures. Among mandibular fractures, the mandibular body was the most fractured site (n = 49, 5%). As for the fracture distribution according to gender, the most common fractured bone for males is the orbital bone, while the most common fractured bone for females is the nasal bone. There was no significant correlation between gender and any of the types of maxillofacial fracture (p > 0.05).
Table 2.
Distribution of maxillofacial fractures.
| Fractures | N | Percent |
|---|---|---|
| Frontal Bone | 144 | 14.72% |
| Zygomatic Bone | 116 | 11.86% |
| Maxillary Fractures | 180 | 18.40% |
| Le Fort I | 114 | |
| Le Fort II | 35 | |
| Le Fort III | 31 | |
| Alveolar Bone | 36 | 3.68% |
| Nasal Bone | 174 | 17.79% |
| Orbital | 203 | 20.76% |
| Mandibular Fractures | 125 | 12.78% |
| Coronoid | 20 | |
| Ramus | 20 | |
| Mandibular Angle | 15 | |
| Mandibular Body | 49 | |
| Symphysis | 12 | |
| Condyle | 9 | |
| Total | 978 | 100% |
Table 3.
Patterns of maxillofacial fractures according to gender.
| Fractures | Female N | Male N |
|---|---|---|
| Zygomatic bone | 7 | 109 |
| Frontal bone | 9 | 135 |
| Orbital fracture | 12 | 191 |
| Le fort I | 6 | 108 |
| Le fort II | 1 | 34 |
| Lef fort III | 2 | 29 |
| Alveolar bone | 2 | 34 |
| Coronoid | 2 | 18 |
| Ramus | 2 | 18 |
| Mandibular angle | 1 | 14 |
| Mandibular body | 5 | 44 |
| Symphysis | 1 | 11 |
| Condyle | 1 | 8 |
| Nasal bone | 18 | 156 |
3.3. Associated injury
Concomitant injuries to other organ systems were reported in 384 patients. As shown in Table 4, head injury (n = 301) was found to be the most common associated injury with maxillofacial trauma, followed by chest injury (n = 255), abdomino-pelvic injury(n = 183), limb injury (n = 130), and spinal injury (n = 56). Concomitant injuries were most caused by road traffic accidents (62.5%), followed by pedestrian trauma (17.21%) and falls (10.67%). The incidence of associated injuries was not statistically associated with age or gender.
Table 4.
Associated injury.
| Associated injury with MFT | Number | Percentage of total MFT |
|---|---|---|
| Brain injury | 301 | 78.4% |
| Chest injury | 255 | 66.4% |
| Abdomino-pelvis injury | 183 | 47.6% |
| Limb injury | 130 | 33.8% |
| Spinal injury | 56 | 13.6% |
3.4. Etiology of maxillofacial fractures
Causes of maxillofacial fractures are shown in Table 5 and Fig. 1. Most of the patients sustained their maxillofacial injuries due to motor vehicle accidents (n = 263, 62%), followed by pedestrian trauma (n = 69, 16.4%). The number of males and females with fractures caused by motor vehicle accidents is not statically significant (p = 0.12). Among motor vehicle-related fractures, the nasal bone was most frequently involved (n = 126 fractures). Fall-related fractures were most common in orbital bone (n = 31 fractures), followed by frontal bone (n = 20 fractures). For zygomatic bone fractures, motor vehicle accidents were responsible for 67 fractures, followed by pedestrians with 21 fractures.
Table 5.
Etiology of maxillofacial Fractures.
| Fracture | Cause of injury |
||||||
|---|---|---|---|---|---|---|---|
| MVA | Motorcycle | Pedestrian | Stab wound | Gunshot | Fall | Others | |
| Coroniod | 13 | 1 | 4 | 0 | 0 | 2 | 0 |
| Ramus | 14 | 2 | 3 | 0 | 0 | 1 | 0 |
| Mandibular Angle | 9 | 1 | 3 | 0 | 0 | 1 | 0 |
| Mandibular Body | 33 | 5 | 7 | 0 | 0 | 4 | 0 |
| Symphysis | 9 | 2 | 1 | 0 | 0 | 0 | 0 |
| Condyle | 7 | 0 | 1 | 0 | 0 | 0 | 0 |
| Zygomatic Bone | 67 | 9 | 21 | 1 | 1 | 16 | 1 |
| Frontal Bone | 82 | 9 | 29 | 1 | 1 | 20 | 0 |
| Orbital | 114 | 15 | 40 | 1 | 0 | 31 | 1 |
| Le Fort I | 67 | 5 | 25 | 0 | 2 | 13 | 1 |
| Le Fort II | 27 | 1 | 6 | 0 | 0 | 1 | 0 |
| Le Fort III | 22 | 4 | 2 | 0 | 1 | 2 | 0 |
| Alveolar Bone | 27 | 0 | 3 | 0 | 1 | 4 | 0 |
| Nasal Bone | 126 | 6 | 25 | 2 | 0 | 11 | 2 |
Fig. 1.
Etiology of maxillofacial Fractures.
4. Discussion
Traumatic injury is one of the most prevalent health concerns worldwide. Among the numerous injuries, maxillofacial fractures is one of the most common due to the anatomically exposed position of the face. The purpose of this epidemiological study was to investigate the prevalence and etiology of maxillofacial fractures in a tertiary hospital in Saudi Arabia.
Our study found that motor vehicle accidents are the leading cause of maxillofacial fractures, representing 62% of the etiologies. Followed by pedestrian trauma at 16.4%, falls at 10.7%, and motorcycle accidents at 6%. Prior studies conducted in Saudi Arabia also reported similar results attributing motor vehicle accidents as the leading cause of maxillofacial fractures (Alghamdi et al., 2017, Ali-Alsuliman et al., 2018). The results in our region correspond to international data in Malaysia (Abosadegh et al., 2017, Chelvan et al., 2020) and South India (Patil et al., 2018). On the contrary, a multicentric European study has found that the primary cause of faciomaxillary fractures is assaults, followed by falls, sports accidents, and road traffic accidents (Boffano et al., 2015a). An additional study conducted in Spain revealed that assaults accounts for 43% of maxillofacial fractures, followed by falls (32%) and motor vehicle accidents (14%) (Jariod Ferrer et al., 2018). The variation in these outcomes may be attributed to a variety of factors including environment, socioeconomic conditions and cultural aspects of the population studied. Moreover, deprived social and economic status was linked to greater susceptibility to facial traumatic injuries. A higher proportion of maxillofacial fractures resulting from motor vehicle accidents occurs in low- and middle-income countries compared with developed countries (Hyman et al., 2016, Romeo et al., 2022).
The mean age of our population was 31 years old. Our data corresponds to the data in the literature, where the age group distribution was mainly between 20 s and 30 s years of age (Al-Bokhamseen et al., 2019, Boffano et al., 2015a, Patil et al., 2018). The nature of the social and economic activities young individuals partake in might be indicative of their increased susceptibility to traumatic injuries of all sorts; therefore, maxillofacial fractures are a common injury in this age group (Pollansky sIlva FarIas et al., 2017). Regarding the genders of the affected individuals, our data has shown that males have a higher incidence of maxillofacial fractures than females, with males representing 91.8% of our population and females representing 8.2%. Similar results were reported in the kingdom, where maxillofacial fractures are more prevalent in males, with percentages of 89.3% in Alhafouf (Al-Bokhamseen et al., 2019), 86.4% in Jeddah (Alghamdi et al., 2017), and 88.6% in Riyadh (Ali-Alsuliman et al., 2018). Other studies conducted in different countries, have consistently found a higher frequency of maxillofacial injuries among males than females (Gupta et al., 2015, Septa et al., 2014, Singaram et al., 2016).
Unlike multiple studies in the region, our study has found that the most common maxillofacial bone fracture is the orbital bone, with a percentage of 20% of our population consisting of 203 fractures, followed by maxillary fractures, nasal fractures, frontal fractures, mandibular fractures, zygomatic fracture, and the alveolar bone fracture. Studies in the respective regions, Alhafouf, Southern Region, Riyadh, and Al Madina, have stated contrary results and and indicate that the most commonly fractured bone was the mandible. Moreover, the European Maxillofacial Trauma (EURMAT) project also demonstrated similar results, reporting that mandibular fractures are the most prevalent fractured bone (Boffano et al., 2015b). However, mandibular fractures were found to be the sixth most common fractures in our population, consisting of 105 fractures in total, with fractures to the body of the mandible making the majority of the total number of fractured mandibles. In addition, our data revealed that the orbital bone is the most fractured maxillofacial bone in males, while in females, the nasal bone is the most commonly fractured. In terms of associated body injuries, a total of 384 patients were found to have concomitant injuries with head injuries being the most prevalent (78.4%), followed by chest injuries with (66.44%). Similarly, A study conducted in Malaysia, demonstrated that traumatic head injuries are common among patients with maxillofacial fractures (Abosadegh et al., 2017). This can be attributed to the proximity of maxillofacial bones to the cranium. In contrast, a study conducted in Riyadh, found that orthopedic injuries were the most common injury associated with maxillofacial fractures, with a percentage of 36%, followed by brain injuries at 25% (AlHammad et al., 2020). Our study showed that motor vehicle accidents are associated with a high rate of concomitant injuries, ICU admissions, and mortality. These findings indicate that motor vehicle accidents significantly impact hospital resources and individual health.
One limitation of this study was that some patient records were incomplete or lacked proper documentation. Another is that this study is based on data from a single tertiary center and does not reflect all hospitals in the city, country, or region. In addition, data from the present study was obtained from the KAMC trauma registry, therefore, patients who were not triaged as level I or II trauma were omitted, since they were not included in the data registry.
Further studies about the morbidity and mortality resulting from maxillofacial fractures should be conducted to evaluate the severity and magnitude of those fractures on the quality of life. Moreover, the data from our study emphasizes the need to improve road safety protocols and advocates to raise awareness about road safety and enforcement of traffic laws.
5. Conclusion
Our study has further vindicated that motor vehicle accidents continue to be the leading cause of maxillofacial injuries in Saudi Arabia despite laws and guidelines addressing their prevention. Young males in their early fourth decade of age are more likely to be the victims of maxillofacial fractures. Nevertheless, orbital bone fractures were found to be the most common maxillofacial bone fractures preceded by maxillary fractures.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgment
The authors would like to thank King Abdullah International Medical Research Center (KAIMRC) for the approval of this study.
Footnotes
Peer review under responsibility of King Saud University. Production and hosting by Elsevier.
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