Maxillofacial Trauma 4 Year prospective study at a tertiary centre in Western Nepal

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1 ORIGINAL RESEARCH Maxillofacial Trauma 4 Year prospective study at a tertiary centre in Western Nepal Rajib Khadka*, Nitesh Kumar Chaurasia** Abstract Purpose: Study was conducted to find the epidemiological characteristics of maxillofacial trauma in the western region of Nepal. Methods All the trauma patients who attended the Department of Oral and Maxillofacial Surgery in 4 year period at a tertiary centre in western Nepal were included in the study. The incidence, prevalence, age and sex distribution, etiology and types, seasonal and daily variation of maxillofacial trauma were studied. Results: Maxillofacial trauma in the region with male (71.55%) predominance and the highest incidence in the age group of years were seen. Road traffic accident (RTA, 46.5%) under influence of alcohol (41.65%), on rural roads (38.9%) due to motorcycle accidents (43.3%) on Friday (36.7%) & in winter seasons (51.2%) were most common. Mandible fractures (65.85%) were more common than Midface fracture (53.58%) & % were the combined Midface & mandible fracture. Parasymphysis in mandible (32.16%) & zygoma (39.09%) in Midface were most common. Conclusion: The increased incidence of maxillofacial trauma following RTA noted in this study reveals the need for formulating preventive measures in western region of Nepal. Inculcate civic sense amongst public through various media resources. Proper traffic management, prevention of carrying excessive passengers especially on roof top of vehicles on the highway & disposal of out of date vehicles & timely maintenance of faulty roads is must. (Khadka R, Chaurasia NK. Maxillofacial Trauma 4 Year Prospective Study at a tertiary centre in Western Nepal ; 3(1): 5-9. Key words: Maxillofacial trauma, Nepal, Mandibular fractures, Midface fractures. Introduction Incidence of maxillofacial trauma is almost always associated with motor vehicle accidents & *Associate Professor, Department of Maxillofacial Surgery, BNB Hospital. **PG Resident of Oral & Maxillofacial Surgery, Stomatological Hospital of Jiamusi University, Heilongjiang Province, Jiamusi, Peoples Republic of China. Address for Correspondence: **Dr. Nitesh Kumar Chaurasia drniteshk@gmail.com interpersonal violence. Other causes include sports related injuries, occupational hazards & gunshot injuries 1,2 However, etiological factors have varied in between country & region of study 3,4. Similarly patterns of fracture have also variability between different regions of study. Studies to determine the etiology & types of fracture patterns in the region helps health care providers to identify the risk factors, formulate plans to decrease the incidence of maxillofacial trauma & to provide proper management care. No studies have been done so far to find out the etiological factors and to estimate the extent of various maxillofacial trauma patterns in the western region of Nepal. The study was carried out at a tertiary center in the Western

2 6 Khadka & Chaurasia region of Nepal which caters to the management of major maxillofacial trauma. The profile of the maxillofacial trauma from the western region of Nepal was studied by analyzing the trauma patients reporting to the Emergency as well as Department of Oral and Maxillofacial Surgery. A prospective study was conducted for a period of 4 years starting from 1 st Jan 2008 to assess the epidemiological characteristics of various maxillofacial trauma patterns. The purpose of the study was to determine age, sex & etiology of maxillofacial trauma, incidence of maxillofacial trauma due to road traffic accidents on different roads; viz national highway, pattern & demographic distribution of fractures at different sites of maxillofacial skeleton & also to evaluate the seasonal & daily variation as well as influence of alcohol on the incidence of maxillofacial trauma. Materials and Methods All the patients with trauma to maxillofacial region attending the Department of emergency & Department of oral & maxillofacial surgery from January 2008 to January 2012 were included in this study. We included the personal data, date of injury, cause of injury & clinical signs & symptoms of the patients. Detailed clinical examinations were done & diagnosis was made on the basis of signs & symptoms, investigations including X-rays & CT scans. Types of fractures were recorded. Mandible fractures were recorded as Symphysis, Parasymphysis, Body, Angle, Ramus, Condyle, Coronoid & Dentoalveolar fractures. Midface fractures were recorded as Dentoalveolar, Le Fort I, II & III, Zygoma, Nasal, Orbital, & palatine fractures. Road traffic accidents (RTA) were analyzed regarding type of vehicle (motorcycle, light motor vehicle, heavy motor vehicle or bicycle), road types (national highway, city road or rural road) & whether injured person was directly involved with vehicle (passenger or driver) or was pedestrian. Data regarding influence of alcohol was also recorded whether injured person was drunk at the time of accident or alcohol by any means was involved in. The data obtained were analyzed statistically. Result Total numbers of patients were 689 & total numbers of fractures were 864. Number of male patients was 493 (71.55%) & number of female patient was 196 (28.45%). Male and female ratio was 2.5:1. Mean age of patients was 33.2 years (SD 13.18). Most common etiology was RTA (321, 46.5%) followed by fall (220, 31.93%). Interpersonal violence was the cause of maxillofacial injury in 102 patients (14.8%), sports related injury in 25 (3.6%), occupational hazards in 21 (3.04%). [Table1]. Table 1: Etiological distribution of maxillofacial trauma (n = number of patients) Etiology Number (n=689) Road traffic accidents (RTA) 321 (46.50) Fall 220 (31.93) Interpersonal violence 102 (14.80) Sports injury 25 (3.62) Occupational hazards 21 (3.04) Majority of injury that was due to RTA was because of motorcycles accidents (139, 43.3%), followed by Light motor vehicles (85, 26.47%), heavy motor vehicles (55, 17.13%) bicycles or rickshaw (42, 13.08%) [Table2]. 296 patients (92.2%) were directly involved in accidents i.e. they were either driver of vehicle or passengers. 25 patients (7.78%) were indirectly involved i.e. they were pedestrian. 125 (38.9%) cases out of 321 cases of RTA occurred on rural road followed by 107 (33.33%) on city road & 89 (27.7%) on national highway. Alcohol by any means was found to be involved in 287 (41.65%) out of 689 cases of maxillofacial trauma. Table 2: Distribution of maxillofacial trauma according to victims, vehicles & roads Variable Number (%) Type of victim Vehicle Roads Drivers/passengers 296 (92.2) Pedestrian 25 (7.78) Motorcycle 139 (43.3) Light motor vehicle 85 (26.47) Heavy motor vehicle 55 (17.13) Bicycle / Rickshaw 42 (13.08) Rural roads 125 (38.9) City roads 107 (33.3) National highway 89 (27.7) Out of 287 cases in which alcohol was consumed, 215 cases (74.9%) of maxillofacial trauma were due to RTA & 72 (24.1%) were due to interpersonal violence & other causes [Table3].

3 Khadka & Chaurasia 7 Majority of the cases of maxillofacial trauma occurred on Friday (253, 36.7%) followed by Saturday (101, 14.65%). Most number of maxillofacial trauma occurred in winters in the month of November to March (353, 51.2%). Table 3: Distribution of maxillofacial trauma under influence of alcohol (n=287) Etiology Number (%) RTA 215 (74.9) Interpersonal violence 72 (25.08) Fracture of mandible was the most common fracture of maxillofacial skeleton (569 out of 864 fractures, %), % of total fractures (463 out of 864) were Midface fractures, 168 (19.44 %) of total fractures were combined Midface & mandible fracture [Table4]. Table 4: Distribution of maxillofacial fracture Fracture Number (%) Mandible 401 (46.41) Midface 295 (34.14) Midface & mandible 168 (19.44) In mandible, parasymphysis fracture was the most common fracture (183, 32.16%) followed by condyle (119, 20.91%), symphysis (94,16.5%), angle (70, 12.30%), body (62, 10.8%) & ramus (41, 7.20%) [Table5]. Table 5: Pattern of Mandible & Midface fractures Mandible (n=569) Midface (n=463) Types Number (%) Types Number (%) Parasymphysis 183 (32.16) Zygoma 181 (39.09) Condyle 119 (20.91) Lefort (23.03) Symphysis 94 (16.52) Orbital 67 (14.44) Angle 70 (12.30) Lefort 2 40 (8.66) Body 62 (10.89) Palatine 20 (4.31) Ramus 41 (7.20) Lefort 3 14 (3.02) Symphysis & bilateral subcondyle fracture was the most common type of combination fracture in mandible (45, 35.15%) followed by parasymphysis & angle (42, 32.81%) & bilateral parasymphysis (41, 32.03%) [Table6]. In mid face, most common type of fracture was fracture of zygoma (181, 39.09%), followed by Le fort I (108, 23.3%), orbital fracture (67, 14.44%), Lefort II (40, 8.66%), nasal (33, 7.12%), palatine (20, 4.31%) & Lefort III (14, 3.02%) [Table5]. Total numbers of Dento-alveolar fractures were 241 (27.89%). Table 6: Combination fractures in mandible Combination fracture Number (%) Symphysis & bilateral subcondyle 45 (35.15) Parasymphysis & angle 42 (32.81) Bilateral parasymphysis 41 (32.03) Discussion Different studies have indicated that maxillofacial trauma is more common in males than in females. Result of our study is also similar to that of other studies. However major cause of maxillofacial injuries varies between areas of study. Recently Rashid et al in their study in London hospital found that interpersonal violence was the most common cause. Many studies have found interpersonal violence to be to be a major cause for maxillofacial trauma 5-7. Interpersonal violence as a major cause in maxillofacial trauma in this part of world is relatively higher than other parts 8. We in our study found that RTA was the major cause of maxillofacial trauma. Majority of RTA were due to motorcycle accidents & alcohol consumption & they occurred on Friday. Many authors have found that alcohol consumption & incidence of maxillofacial trauma has a positive relation in between them 5,7,9-11. Studies have also found interpersonal violence to be a major cause of maxillofacial trauma when alcohol is involved 7,11-13 but in our study we found that majority of cases in which alcohol was consumed was due to RTA which is in contrast to numerous studies conducted elsewhere. The reason for this to be more common in Nepal could be a free availability of alcohol in Nepal. We also found motorcycle accidents to be more common causes which is similar to results by Atanosov & Wong 14,15. Variations in the incidence of maxillofacial trauma on different days of a week have also been reported in many studies & they have found it to

4 8 Khadka & Chaurasia be most common on the weekends In our study, we found Friday to be most common day of occurrence of maxillofacial trauma. Friday is last working day of a week & people feel to relax & enjoy & alcohol as easily available has become one of the main mode of enjoyment. Similarly road accidents are increasing in Nepal due to increased vehicle fleet & speed. According to national statistics, more than 11,000 people were injured due to RTA in 2009/10 & are increasing year by year. Many of the accidents have not been reported to police so the number could be even more. We found RTA to be common on rural roads which could be due to faulty tracks & ditches & lack of traffic awareness in rural population. Besides these seasonal variations regarding incidence of maxillofacial trauma have also been reported in various studies 17,19. Ogundare in their studies found that maxillofacial trauma were more common in summer than in winters 19. We in our study found that maxillofacial trauma in this reason were more common in winters. The weather in winters in western Nepal is very foggy & visibility is very low. In addition hilly roads and consumption of alcohol to keep one warm during winters could be one of the reason for RTA to occur which increases the incidence of maxillofacial trauma. Pattern of fractures also vary in study. Studies have found Body of the mandible, angle of the mandible or condyle & subcondyle to be the most common site of fractures 20,21. We in our study found that mandible was more commonly fractured than Midface & parasymphysis was the most common site of fracture followed by condyle. Nepal is a developing country. Majority of cases of maxillofacial trauma in our study due to RTA & motorcycle accidents involved mainly under influence of alcohol & in rural roads indicates that there needs to be awareness in general people about influence of drink & drive. Following traffic rules, use of seat belts & helmets, not carrying passengers more than the capacity of vehicle, disposal of out of date vehicles, timely maintenance of faulty roads needs to be extremely necessary. Recently drink & drive law has been enforced in Nepal & hopefully this will bring down the rates of RTA & trauma. We hope that the study conducted would help health care workers to identify the major etiological factors involved in maxillofacial trauma in the region & provide proper care of trauma patients. Conclusion Maxillofacial trauma is more common in males than in females & is more common between years of age. There is an increased incidence of maxillofacial trauma due to alcohol consumption & RTA due to motorcycle accidents is most common etiology. As majority of these trauma occurred on Friday which is also a weekend in Nepal- time for relaxation, thus we need to aware people to avoid drink & drive. Mandible is more commonly fractured than Midface. Parasymphysis in mandible & zygoma in Midface is the most common fracture of maxillofacial region. References 1. Erol B, Tanrikulu R, Gorgun B. Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg Oct;32(5): Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg Feb;31(1): Laski R, Ziccardi VB, Broder HL, Janal M. Facial trauma: a recurrent disease? The potential role of disease prevention. J Oral Maxillofac Surg Jun;62(6): Bormann KH, Wild S, Gellrich NC, Kokemuller H, Stuhmer C, Schmelzeisen R, et al. Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications. J Oral Maxillofac Surg Jun;67(6): Lee JH, Cho BK, Park WJ. A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg Apr;38(3): Lee K. Trend of alcohol involvement in maxillofacial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Apr;107(4):e Lee KH, Snape L, Steenberg LJ, Worthington J. Comparison between interpersonal violence and motor vehicle accidents in the aetiology of

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