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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 63-70

Epidemiology and incidence of traumatic head injury associated with maxillofacial fractures: A global perspective


Department of Maxillofacial Surgery, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Shaifulizan A. B. Rahman
Department of Maxillofacial Surgery, Maxillofacial Surgery Unit, School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_9_18

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  Abstract 

Traumatic head injuries (THIs) associated with maxillofacial fractures (MFFs) are large public health concern worldwide, especially among adult-aged males. The MF injuries accompanied with THI involve serious esthetic and functional problems that lead to various consequential complications; therefore, early detection of associated THI in patients with MFF is the urgent need for initial assessment and treatment planning because it can reduce morbidity and mortality and enhance the outcome of treatment in those patients. The present review provides current updates for THI associated with MFF among different countries considering the prevalence, age, sex, etiology, and types of MFF in patients with THI throughout the world. The young adult males in the age group of 20–39 years were the most sustained THI associated with MFF. Road traffic accident (RTA) was the most common etiology of injury followed by assault, fall, and the other causes represent very low percentages. The types of MFF (orbital, zygoma, maxilla, and mandible) were associated with THI in MFF patients. Within the limits of the reviewed THI associated with MFF literature, it was concluded that civilization, culture, adult age group, male gender, RTA, and assault were the major factors that determine the trends of THI-related MFF. In this study, we recommend improving public awareness by applying road traffic regulations, encouraging the rules for compulsory use of seat belts and helmet, avoiding risky driving, and enhancing road quality.

Keywords: Association, epidemiology, incidence, maxillofacial fractures, traumatic head injuries


How to cite this article:
Abosadegh MM, Rahman SA. Epidemiology and incidence of traumatic head injury associated with maxillofacial fractures: A global perspective. J Int Oral Health 2018;10:63-70

How to cite this URL:
Abosadegh MM, Rahman SA. Epidemiology and incidence of traumatic head injury associated with maxillofacial fractures: A global perspective. J Int Oral Health [serial online] 2018 [cited 2018 Sep 25];10:63-70. Available from: http://www.jioh.org/text.asp?2018/10/2/63/230864


  Introduction Top


Traumatic head injuries (THIs) are usually concomitant with maxillofacial fractures (MFFs), and the MFF can be considered as significant indicators for THI.[1],[2] Due to the close anatomic proximity of MF bone and cranium, usually the patients with MFF are at an increased risk of and suffer from THI simultaneously which can lead to primary or secondary brain damage in case of a miss or late diagnosis in such cases.[3],[4]

Globally, THI will exceed many other diseases as the main cause of disability and death by the year 2020 according to the World Health Organization (WHO) since it is a significant public health problem because it impairs brain function and it often results in negative long-term or permanent physical, cognitive, behavioral, and emotional changes.[5] To date, the risk effect of MF injury on the brain has not been properly documented, with some suggesting that it has a protective function on the brain while others opposing this idea.[3],[6],[7]

The MF injuries accompanied with THI are considered complex in nature as they might involve serious esthetic and functional problems and thus they are clinically described as consequential. This makes accurate diagnostic evaluation necessary, especially in acute stage to clarify emergent injuries; to preoperatively plan the reconstruction of functional areas (e.g., vision, mastication, and olfaction); and to guide the physical, psychological, and social rehabilitation process.[8],[9] Early detection of associated THI in patients with MFF is the most important procedure for rapid assessment and stabilization of patients and for initial assessment and treatment planning because it can reduce morbidity and mortality and enhance the outcome of treatment in those patients.[3],[10]

THI is defined as nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.[11] Another definition used to describe THI is that it is a heterogeneous disease including a broad range of pathology processes, involving, for example, diffuse axonal injury, cerebral contusions, epidural hematoma (EDH), subdural hematoma, and subarachnoid hemorrhage (SAH).[12] THI defined by the Centers for Disease Control and Prevention is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.[13]

There are different ways to classify patients with THI; it has been commonly classified by one of the three main systems: a physical mechanism of injury, clinical indices of injury severity and morphology, or patho-anatomical of injury [Table 1].[14]
Table 1: Classification of traumatic head injuries

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Maxillofacial fracture

The increasing pace of modern life, high-speed travel, growing frequency of violence, crowded society, the magnitude of traffic accidents, sports injuries, wars, and industrial trauma, etc., have made MFF a form of social disease from which no one is immune.[15] MFF is considered one of the most common injuries among the myriad injuries which attend to emergency departments of hospitals around the world. Trauma to this area mandates special attention during diagnosis; because of their close anatomical proximity and frequent involvement, the vital structures in the head-and-neck region must be evaluated whenever the head and face are injured.[16]

Due to the anatomical complexity of the MF region and the difficulties to obtain high-quality imaging study in severely traumatized patients due to their clinical conditions and inability to cooperate, MFFs are challenging and difficult for clinical and radiological evaluation also.[17]

Classification of maxillofacial fracture

MFF can affect single or multiple bones in the facial regions. Due to the complexity of that area, it is usually not easy for the physician to classify the MFF simply according to the bones involved.[17] MFFs are classified into central mid-face fractures, lateral mid-face fractures, and mandibular fractures.

  1. Central mid-face fractures include nasal fractures, naso-orbital-ethmoid (NOE) fracture, orbital wall fracture, maxillary sinus fracture, Le Fort I fracture, Le Fort II fracture, and Le Fort III fracture
  2. Lateral mid-face fractures include zygomatic-malar complex fracture, zygomatic arch fracture, and orbital floor fracture
  3. Mandibular fractures are classified according to the anatomic location of fractures as symphysis fractures, alveolar process fractures, body or horizontal ramus fractures, angle fractures, ascending ramus fractures, coronoid process fractures, and mandibular condyle fractures. The classification of mandibular fractures by this way is simple and correlates anatomical and clinical nomenclature.[18]


Etiology of maxillofacial fracture

Several studies in different countries around the world have been conducted to determine the etiology of MFF. The main causes of MFF worldwide frequently vary from one country to another and also in the same country. This large variability in reported etiology is due to a variety of contributing factors such as cultural, environmental, and socioeconomic factors.[6],[19],[20],[21],[22] For the purpose of research, the most common etiology of MFF has been divided into several categories including road traffic accidents (RTAs), assaults or interpersonal violence, sports, falls, and other etiological causes.

Road traffic accidents

The WHO made RTA definition as a collision involving at least one vehicle in motion, on a public or private road, that results in at least one person being injured or killed.[23]

Traditionally, the most common cause of MFF in both developed and developing countries has been considered to be RTA. This fact remains true for developing countries.[8] However, there is a significant inclination of the MFF rates associated with RTA in developed countries which may contribute to several factors such as high public education and behavioral changes, limitation of speed during driving, using shoulder and seat belts, wearing the helmets by motorcycle drivers, alcohol restriction, improvement of road quality, better motor vehicle safety, effective legislation, and law implementation.[24]

In general, there is a high rate of RTA-related MFF seen in Asian, Middle-Eastern region, African, and South American countries. The collected data from different countries such as India, Japan, the United Arab Emirates, Pakistan, Turkey, and Brazil show that 36%–75% of MFFs were related to RTA.[7],[25],[26],[27],[28],[29],[30],[31] The underlying reasons for that high rate include absence or defects of road traffic regulations and its application, lack of legislation regarding compulsory seat belts and helmet, risky driving, bad road quality, less safety of the vehicles, and increased usage of motor vehicles and cycles. The most important factor is the forbidden of alcohol drinking in Islamic countries according to their religion which may effectively lead to lower rates of assault-related MFF, thus making the proportional contribution of RTA higher.[32]

Assaults or interpersonal violence

The WHO defines interpersonal violence, which is usually known as assault, as the intentional use of physical power or force of someone, actual or threatened, against another one, that either directly results in or has a high probability or resulting in injury, psychological harm, death, or mal-development or deprivation. Assault or interpersonal violence can also subdivide into youth violence, intimate partner violence (IPV), child maltreatment, elder abuse, and sexual violence.[33]

A study from New Zealand by Lee for 11-year period shows that the trend of IPV-related to MFF accounts for 44% of all patients.[34] Globally, some recent reports from different countries have shown that the assault presides the other causes of THI with MFF in Turkey, the Netherlands, North America, Bulgaria, Switzerland, and South Africa.[1],[12],[21],[22],[35],[36] Other studies refer to an increase in IPV and a decrease in RTA as a cause of facial fractures due to alcohol abuse and growing aggression in the society.[26],[37]

Sports-related injuries

MFF can be seen in both contact and noncontact sports. The injuries may arise if the participant collides with an opponent or with a teammate, sporting equipment, or an aspect of the setting in which the event organized. Due to changing trends in the etiology of MFF, the fractures associated with sports seem to be more common nowadays. Traditionally, sports were the third most common reason for MFF, after RTA and assaults.[38] However, regardless of the percentages, many research studies suggest that MFFs related to sports have exceeded those related to RTA, making it the first or second most common cause of MFF in some countries after injuries due to assaults.[37],[39],[40]

There is strong evidence of a relationship between MFF and patient demographic characteristics regardless of the type of sports and country, which explains why the majority of these types of fractures are seen in young adult males aged from 20 to 30 years due to a high level of physical activity on this age group. On the other hand, the risk of a sport-related MFF decreases with elder people more than 50 years old.[41]

Fall-related injuries

The WHO defines falls as “inadvertently coming to rest on the ground, floor another level, excluding intentional change in position to rest in furniture, wall or other objects.”[42] Several factors contribute to the assessment of MFF related to falls such as patient's age (i.e., falls in the pediatrics or in old patients), the height of falls (at level surfaces or from heights), and the cause of the falls such as slipping and tripping, loss of consciousness, and epilepsy.[43]

Falls can occur on level surfaces and from a height, and the impact of trauma is different in these circumstances. MFFs resulting from fall down or fall from height show a considerable percentage of fractures that occur mainly in young adult females and in the older adults.[43] In older people, the MFFs related to falls are a significant threat to the health and account for around 70% of all fractures in this age group in developed countries.[43],[44],[74] This finding is clearly reported as MFF is more common in females when compared to males after the age of 72 years due to the higher proportion of females in that age group as a result of their long life span.[32] Incidental falls, sports, and RTA remain the most common causes of MFF among children.

Other etiological causes

Other causes of MFF involve work-related injuries, pathological fractures, medical misadventure, suicidal attempts, and other unintentional injuries. The percentage of MFF relating to this category is very low. Although other causes of facial fractures must not be excluded, they may not be regarded as the primary focus.

Association of traumatic head injuries among patients with maxillofacial fracture

The association between THI and MFF has not been firmly established in the literature. Several small studies have discussed the association of THI among patients with MFF in particular and the results of those studies are varied. Most of those studies, however, have described neurologic injury in general terms rather than specific injuries.

The differences and conflicts in studies regarding the association of THI with MFF globally are very wide. The prevalence of THI in a patient with MFF ranges from 7.6% to 8.9% in some studies,[21],[45] while in other studies, this percentage can reach up to 86% in more serious MFF.[46] The variations of the results can refer to the habitual, socioeconomic, cultural differences in the studied populations as well as the differences in the etiology and methodological criteria applied in various studies.[1],[3],[21],[31],[47]

Examination of the literature found differing hypothesis regarding the effect of MFF on the incidence and occurrence of THI as anatomically the brain is an adjacent position to those MFFs. Some researchers state that MFFs in bones, especially in the case of maxillary and midfacial bony fractures, act as a shock absorber for the high-impact energy of the trauma, protecting the brain, especially in the case of intracranial hemorrhage from trauma.[48],[49] However, other researchers suggest the reverse that high-velocity impacts with sufficient force to cause MFF may also transmit to the brain and cause THIs such as intracranial hemorrhage. In another meaning, MFFs are a marker for increased risk of THI.[50],[51],[52],[53]

The largest study of the association of THI among MFF patients was reported by Mulligan et al. which included more than 1.3 million patients with injuries from more than 700 hospitals across the USA. Nearly 67.9% of patients with MFF had THI. Of them, 29.5% had skull fractures followed by intracranial hemorrhage in 28.6%, brain contusion/laceration in 16.9%, and concussion with loss of consciousness in 11.2%.[47]

A retrospective study conducted for a 7-year period in Level 1 trauma center, University of Louisville Hospital, USA, by Martin 2ndet al. to evaluate the association between facial fractures and brain injuries found that 79.4% of patients with facial fractures suffered from types of THI. Male patients were the most common suspected cases with a median age of 34 years. Motor vehicle accident (MVA) was the most common etiology (65.4%) followed by fall and assault (25.7%) and almost 5% due to motorcycle accident (MCA). They concluded that the face does not provide a protective effect for the brain as they found that the MFF with THI occurs significantly greater than MFF without THI (P< 0.001).[53]

A demographic study done by Yasir to evaluate the prevalence of facial trauma among patients with head injuries in Pakistan found that 76% of patients had facial trauma associated with THI. In gender distribution, male patients were the most common suspected cases (74%) compared to females (26%) with the most affected age group to be 15–30 years. RTA including MCA, MVA, and pedestrian was the most common cause of facial trauma associated with THI (39%) followed by fall (26%). He suggested that the reasons for this high prevalence of head injuries with MFF in this age group could be related to economic and social activities of this age group such as driving motor vehicles rashly and increased violence among them.[31]

In Turkey, a study conducted by Arslan et al. on 754 patients attending to emergency department reported that 8.9% of patients with MF trauma had THI; 73.7% of these patients were male and 26.3% were female, with the predominant age group being 18–39 years. Violence was the leading cause of THI in MF trauma cases (47.8%) followed by falls in 28.4% and RTA in 20.9%. The most common THI type was SAH (44.8%) followed by contusions (22.4%) and EDH (20.9%). Of patients with THI, 33 patients had a mild head injury (Glasgow Coma Scale [GCS] score: 13–15), a moderate head injury (GCS score: 9–12) was found in 18 patients, and 17 patients suffered from severe head injury (GCS score: 3–8). Maxillary bone fracture accounted for 28% of MFF followed by nasal bone fracture (25.3%) and zygoma fracture (20.2%), mandibular fracture (8.4%), and NOE fracture (3.1%).[21]

In a retrospective study conducted by Salentijn et al. regarding the analysis of MF trauma and THI from Amsterdam, the Netherlands, the results revealed that the incidence of THI in 579 patients who have MFF over a period of 10 years was 8.1%. Nearly 89.4% of those patients are male, while only 10.6% are female, with the predominant age group being 20–29 years of both sexes. The RTA was the main cause of MFF related to THI (55.3%) followed by falls (25.5%), interpersonal violence (4.3%), and other causes (only 14.9%). The most common site of MFF was frontal sinus fractures (21.9%) followed by zygomatic complex fractures (16.2%), mandibular bone fractures (16.2%), and Le Fort fractures (14.3%). Regarding THI, they found that 57.4% of patients had severe head injuries and 21.3% had mild and moderate head injuries.[1]

A prospective study conducted by Zandi and Seyed Hoseini from Iran reported that the rate of head injuries associated with facial trauma was 23.3% with the high incidence of head injuries in patients who have facial trauma being commonly found in male patients (88.7%), while female patients reported an incidence of 11.3% with most of them being young patients. The most common cause of injuries was MCA (43.7%) followed by MVA (29.8%) and assaults (16.9%), with the prevalence of nasal bone fracture being 45% followed by mandibular bone fracture (36.4%), zygomatic bone fracture (26.8%), and Le Fort II fracture (22.2%). They reported a higher significant association of MCA (211.30 folds), MVA (139.43 folds), fall (65.9 folds), assault (69.28 folds), frontal sinus fracture (84.5 folds), and Le Fort II fracture which were the strongest predictors of sustained THI.[3]

The results from a recent study reported by Goil et al. from India regarding the association of THI and MF trauma found that 81.3% patients with MF injuries had associated THI with a male predominance and the majority of patients were in the age group of 20–40 years. RTA was the most common cause of THI in patients with MF trauma (92.4%) followed by falls from height (4.16%) and assault (2.3%). Zygoma fracture was observed to have the strongest impact to sustained THI with odds ratio of 3.34 followed by mandible, NOE, maxilla, and supraorbital bone with odds ratios of 2.46, 1.67, 1.36, and 1.15, respectively.[7]


  Materials and Methods Top


We reviewed all articles that were published in the English language without time limitation regarding the association of THI among patients with MFF using Google Scholar, PubMed, NCBI, and Medline. Articles were searched for association, epidemiology, correlation, prevalence of THI, traumatic brain injuries, MFF, concomitant injuries, and a combination of these terms in title.

Inclusion criteria

Articles that presented complete data were included according to the following criteria:

  1. Availability of the full-text article in order to obtain all or most of the characteristics of THI associated with MFF
  2. Retrospective or prospective studies dealing with all age groups (children and adults) and civilian-type injuries
  3. Studies where fractures were received and managed in MF units related to hospitals or emergency units or tertiary of primary units
  4. Studies where the diagnoses of fractures were made on the basis of presenting complaints, clinical examination, and were confirmed radiographically, especially radiographs, clinical examinations, and by the findings at operation.


For each of the included studies, a data collection form was designed and used for the collection of data including country, study interval, age group, male-to-female ratio, percentage of THI associated with MFF, major cause of MFF, the most common type of MFF, and the most common type of THI.

Exclusion criteria

Those that gave epidemiological data only about specific groups or specific conditions (such as children, old people, and military exercises), as well as those that recorded only specific MFF type only, were excluded from the study.


  Results Top


A total of forty studies were included from Africa (n = 6), America (n = 5), Asia (n = 19), and Europe (n = 7) [Table 2], [Table 3], [Table 4], [Table 5]. In all studies, men outnumbered women, the male-to-female ratio usually being more than 2:1. The young adult age group between 20 and 39 years old was the most sustained age group. The global prevalence of THI among patients with MFF was estimated as 7.6% to around 87% of patients, this wide range might be attributed to the criteria of case selection and methods of detecting THI.
Table 2: Associations of traumatic head injuries and maxillofacial fractures in Africa

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Table 3: Associations of traumatic head injuries and maxillofacial fractures in Asia

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Table 4: Associations of traumatic head injuries and maxillofacial fractures in Europe

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Table 5: Associations of traumatic head injuries and maxillofacial fractures in America

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The epidemiological studies showed that the male/female ratio ranged from 2.7:1 to 8:1. RTA had remained the most important etiological cause of THI associated with MFF, with some exceptions in few countries showed that the assault was the major etiology of THI-associated MFF. Orbital, zygoma, maxillary, and mandibular fractures were the most common MFF types associated with THI.


  Discussion Top


The incidence of THI associated with MFF in different countries around the world is higher in males when compared to females.[1],[2],[3],[54],[64] This can be attributed to the high or low percentage of women who participate directly in social, economic, and cultural activities and therefore they are consequently susceptible to traffic accidents, violence, and sports accident. For example, the male/female ratio in most of the studies conducted in developed countries ranged from 2:1 to 4:1, which indicates the active participation of women in outdoor life activities,[19],[20],[56],[57] in contrast to developing countries like India that has increased male/female ratio.[58],[59]

Worldwide, most patients exposed to THI concomitant with MFF are male between 20 and 39 years.[3],[45],[60] It was suggested that this age group frequently practices dangerous exercises, sports, carelessly drive motor vehicles, and engaged in outdoor activities.[61]

The percentage of THI accompanied with MFF ranged from 4.4% to 87% and noted to be significantly different among various demographical population communities within the same or different countries. The reason behind this wide range difference among studies was attributed to the inclusion and exclusion criteria, time interval, the number of patients included, and the applied methodology.[45],[61]

RTAs are still the major etiology of THI associated with MFF [54],[55],[61],[62] without losing sight of other causes such as assault and fall in few counties due to increased number of vehicles, badly maintained roads, insufficient stress on the use of seat belts and helmet, and lack of enforcement of traffic rules and regulations.[19],[45],[61],[62]


  Conclusion Top


The present study provided current updates for the epidemiology of THI associated with MFF. Within the limits of the reviewed MFF and THI literature, it was concluded that adult age group, male gender, RTA, and assault were the major factors that determine the trends of THI-related MFF.

THI should be suspected whenever orbital, zygoma, and maxillary bone fractures are presented. This study provides important data for design of preventive plans; hence, it provides opportunity to assess epidemiology, prevalence, and the association between THI and MFF. We recommend improving public awareness by applying road traffic regulations, encouraging the rules for compulsory usage of seat belts and helmet, avoiding risky driving, and enhancing road quality.

Acknowledgment

We would like to acknowledge Dr. Mustafa Mahmoud and Dr. Khalid Al-Maker for their appreciated support and help with positive comments and correction to improve the manuscript of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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