Basheer Rehman* , Qiam Ud Din**, Murad Ali Shah***, Shuja Riaz Ansari****
- Registrar, Dept of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar .
- Principal & Dean, Dept of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar.
- Dept of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar .
- ****Associate Professor, Dept of Oral & Maxillofacial Surgery, Khyber College of Dentistry, Peshawar
Correspondence: “Dr. Basheer Rehman ” <email@example.com>
How to CITE:
J Pak Dent Assoc 2010;19(3): 158 -163
The purpose of this study was to document the characteristics of maxillofacial fractures resulting from road traffic accidents.
The study was carried on 250 patients presenting with maxillofacial fractures resulting from road traffic accidents. On the basis of history, clinical and radiological examination, fractures were classified as dentoalveolar fracture, mandibular fracture, maxillary fracture (Lefort I, II and III), isolated zygomatic arch fracture, zygomatic complex fracture, nasal bone and orbital fractures. Data was analysed by statistical analysis tool using SPSS version 17.
Males in their 2nd and 3rd decades were the most common victims. Among the isolated bone fractures (n=208), mandible was the most commonly fractured bone (n=104) followed by zygomatic complex (n=50). The frequently observed pattern among mandibular fracture was parasymphysis (31.6%), among zygomatic complex was Group IV (n=29) while maxillary fractures showed a pattern of combined Lefort I, II and III (n=21).
Road traffic accidents are predictable and preventable. Basic knowledge regarding road safety measures and its implementation is necessary. It can be concluded from this study that majority of the patients were young adult males. The most common bone fractured was mandible both in isolation and combination.
Maxillofacial Fractures, Road Traffic Accidents, Facial Trauma.
Road Traffic accidents (RTAs) remain the commonest causes of maxillofacial fractures in spite of introduction of numerous devices improving the safety in motor vehicles.1 The other etiological factors of maxillofacial trauma are falls, assaults, sports, fire arm injuries and industrial accidents.2
RTAs are a major yet neglected public health problem in developing countries. An estimated 1.2 million people worldwide are killed each year and as many as 50 million are injured because of RTAs, occupying 45% of Maxillofacial surgical beds.3 In western industrialized countries 65 to 67% of maxillofacial trauma is caused by RTAs4. Chinese population is having a low incidence of 31%.5 while in Pakistan RTAs contribute to about 56% of maxillofacial trauma.6
The maxillofacial injury is a serious clinical problem. This is the area where the important anatomical structures are located. That is why injuries to maxillofacial region result in serious dysfunctions including damage to the central nervous system7 . The esthetic and psychological aspects of injuries to the maxillofacial region are of great importance, as minor changes in the patient’s facial appearance after trauma may cause severe psychological disruption 8.Maxillofacial fractures include dentoalveolar fractures (DAF), mandibular fractures and zygomaticomaxillary complex (ZMC) fractures alone or in combination. Age and sex have been cited as important factors influencing the occurrence of maxillofacial
fractures caused by RTAs. The highest incidence is seen in age group 21-30 years, probably reflecting inexperience and rash drivind in this age group. The lowest incidence is observed in the age group above 60 years and below 5 years. Male to female ratio is approximately 7:1 showing the male predominance10.Contributory factors involved in traffic crashes and subsequent maxillofacial trauma include uncontrolled speeds, drunken drive, failure to use seat belts, and cell phone use while driving 11 .The economic and social implications of this problem have initiated research in many countries into the incidence and causation of RTAs, the injuries sustained and how these may be treated or alleviated. Special attention is focused on etiologic factors and the trauma mechanisms to successfully prevent these injuries 12. The purpose of this study is to provide a circumstantial evidence for the recommendation of possible preventive measures, and subsequent implementation of traffic legislations.
The study was carried out on 250 patients presenting with maxillofacial fractures resulting from road traffic accidents in Out Patient Department (OPD) of Oral and Maxillofacial Surgical Unit, Khyber College of Dentistry, Peshawar. This study was conducted from June 2007 to May 2008. With the verbal and informed written consent of the Patients or attendants all the necessary information about the variables of the study were collected on preformed proforma Relevant radiographs were taken to diagnose and confirm fractures like, dentoalveolar, mandibular, maxillary, isolated zygomatic arch, zygomatic complex, nasal bone and orbital fractures. The data so collected was compiled and evaluated using SPSS version 17
In one year period between June 2007 to May 2008 a total of 250 patients were recorded and analyzed. Out of these, 208 (83.2%) were males while only 42 (16.8%) were females. Male to female ratio was 5:1. (Fig.1) this study showed an age range of 3-80 years. The most commonly involved agegroup was 3rd decade followed by 2nd decade. Out of 250 patients, 79.2% (n = 198) were found below 40 years of age. Details of age distribution are given in Table.1. Out of total 250 patients, 83.2% (n =208) had isolated bony fractures while 16.8% (n = 42) had combination bone fracture. Among the isolated bony trauma (n= 208) due to RTA, mandible was the most common bone
fractured (n=104) followed by ZMC fractures (n=50), maxillary fractures (n=41) and zygomatic arch (n=4) in descending order. (Table.2).
There were no isolated cases of nasal, orbital and mandibular dentoalveolar bone fractures. Out of total combination bony trauma (n=42), mandible and maxilla were the common bones involved in 50% of the cases (n=21). (Table.3).
Out of 133 cases of mandibular fracture both isolated (n=104) and combination (n=29), parasymphysis fractures were most common (31.6%) followed by body and angle (18.8% each). Fig.2
Combination and isolated zygomatic complex fractures (n=71) were classified according to Knight and North13 classification. Mostly the fracture fall in Group IV (n=29) followed by Group VI ( n=21) as shown in Fig.3.
In isolated maxillary bone fractures (n=41), the characterization of Le Fort fractures was such that the combined Lefort I, II and III fractures were most commonly observed pattern in 51.2% cases (n=21)
The remaining results showed Lefort II & III in 19.5% (n=8) each, while Lefort I in 9.8% (n=4).
The public health importance for countries to assess and evaluate their data on the magnitude, impact and characteristics of RTA cannot be overstated. RTAs are a global health problem and a leading cause of maxillofacial trauma worldwide 4. South Asia is one of the region where maxillofacial trauma resulting from RTA has been rising steadily over the past decade and is expected to increase by two and a half times in the next two decades 14. Kobusingye 15 stated that facial trauma due to RTA have been steadily falling in the developed countries, they continue to rise with horrifying speed in the low income and middle income countries (LMIC). According to World Health Organization (WHO), 25% of all injuries are caused by RTA with 90% occurring in LMIC. The reduction in RTA related maxillofacial trauma in developed countries is largely attributed to a wide range of road safety measures and traffic law enforcement15. Males are predominantly affected in this study accounting for 83.2% with a male to female ratio of 5:1, which correlates well with other studies 10,16 carried out in Pakistan. Similar results were shown by Soori in Iran 17. However studies carried out in United Kingdom 18, Austria 19 and Nepal 20 showed a male to female ratios of 2:1 to 3:1. This difference can be attributed to Islamic culture and socioeconomic status augmented by conservative nature of Pakhtun society particularly in this part of the world, where males are responsible for outdoor works and females are mostly confined to their houses. Only few of the females drive cars
Our findings of highest frequency of RTA related maxillofacial trauma in 2nd and 3rd decades with 79.2% occurring below 40 years of age are in agreement with the studies carried out by Shah 10, Adeyemo 21, and Qureshi 22 . This is easily attributed to the fact that it is the most active phase of life, reflecting inexperience and rash driving in this age group. Mandible was the most common bone involved in 50% isolated bony trauma followed by ZMC (24%) and Maxilla (20%). These findings are comparable to most of the studies done in other parts of the world9,23. The mobility of the mandible and the fact that it has less bony support than the Zygoma and maxilla have been implicated in the frequency of its involvement in trauma9. Among the mandibular fractures, parasymphysis region was most commonly involved (31.6%). Angle of the mandible and body comprised 18.8% each both in isolated and combination type of fractures followed by multi site involvement in 15.0%. Similar findings were recorded by Abbas 6 and Ozkaya23.
The magnitude and direction of the impact force and anatomy of the site influence the pattern of fracture 24. The front impact in RTA and the location of parasymphysis region explains its vulnerability in trauma. The deeply buried impacted third molar teeth as an impetus to the fracture at the angle of the mandible. Another reason has been suggested in this regard is that the angle of the mandible is susceptible to trauma due to abrupt change in direction of trabeculae from horizontal to vertical24. In the present study, among the fractures of the midfacial region, zygomatic complex fractures were most common both in isolation and combination accounting for a total of 71 cases (Table 2 &3). According to Knight and North13 classification, majority of the fractures fall in Group IV (41.18%) in which there was medial rotation of the zygoma. According to this classification Group-I means no clear displacement clinically and radio-graphically, Group-II- zygomatic arch fracture only, Group-III- un-rotated body fracture , Group-IV-medially rotated fractures, Group-V- laterally rotated fractures while Group-VI are complex fractures. These findings are supported by Obuekwe25 The isolated arch fracture is uncommon in this study in contrast to Yamamoto26 and Adeyemo21. This difference is due to the prominent role of frontal impact in RTA. Arch fractures occur mostly due to lateral impact like sports, assaults and missile injuries. The other reason is that in countries like Nigeria and Finland, there has been a significant increase in the number of zygomatic arch fractures resulted from motorcycle accidents. Motorcycles have become a prominent mode of transportation in these countries where most of the motorcyclists usually fell down to their sides after collision which may be the possible cause of arch fracture in this particular group of patients 21. Wide variations have been reported regarding the pattern of maxillary fractures in RTA.
The characterization of Lefort pattern in this study shows that combination of Lefort I, II and III were the most commonly observed pattern accounting for 51.2 % of the maxillary bone fractures. Most of the research workers from Nigeria21 and Australia27 contradict this high percentage of combined Lefort I, II and III pattern. As the forces necessary to cause such fractures also lead to other severe injuries like orbital, nasal and head injuries and in most of these countries such patients are admitted to specialized centers where a team approach is made to treat such patients. Therefore separate data regarding combined Le Fort fractures is not common in maxillofacial units27. Maxillofacial surgery department at Khyber college of Dentistry, Peshawar is the only specialized center in the region dealing with such injuries and most of the patients with injuries of serious nature are also referred and managed here where associated combined le fort fractures are common 28 .
The low percentage (4%) of DAF in our study does not correlate with studies done in India29 (42%), the reason being such injuries are referred to minor oral surgery and paedodontics departments and managed there. Although Hussain 30 has supported this low percentage. The research covering the problem of maxillofacial injuries following steering wheel contact by drivers using seat belts and the hard surfaces in vehicle by other passengers exhibited that the nose fractures had the highest incidence of 43.80% 31. This study demonstrated no isolated cases of nasal bone and orbital fractures. The reason for this finding is that our department is surrounded by three Medical Teaching Hospitals where these isolated cases are managed in their respective units
The use of vehicle is on the rise in developing countries, road traffic injuries are also growing. Road traffic accidents are predictable and preventable and basic knowledge regarding road safety measures and its implementation is necessary. Results showed that young adult males in particular contributed significantly to this study group in terms of morbidity. The most common bone fractured was mandible. It was also seen that mandible and maxilla in combination were the most common pair. Among the mandibular and zygomatic complex fractures, parasymphysis and group IV fractures respectively were frequently seen. All three patterns of Lefort fractures were commonly recorded in combination
In the light of this study the following recommendations can be given
- Research is needed to further uncover factors that distinguish TRA and their characteristics from those occurring in developed c o u n t r i e s . Information gathered can be used to develop novel interventions.
- Regulating informal public transportation systems and enforcing safety legislation like seat belts and restriction of mobile phone use while driving, could go a long way in reducing the burden of RTAs. It is imperative that government makes this issue a top priority alongside other pressing public health problems.
- In order to reduce the incidence of RTA, no person should be given driving license unless the person has learned driving from a registered driving school.
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