Epidemiology of facial injury in blunt assault. Determinants of incidence and outcome in 802 patients

Health Disparities Research in Facial Plastic and Reconstructive Surgery: A Scoping Review

OBJECTIVE

Health disparities contribute significantly to disease, health outcomes, and access to care. Little is known about the state of health disparities in facial plastic and reconstructive surgery (FPRS). This scoping review aims to synthesize the existing disparities research in FPRS and guide future disparities-related efforts.

DATA SOURCES

PubMed, Embase, Web of Science.

REVIEW METHODS

We conducted a scoping review in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. Our search included all years through March 03, 2023. All peer-reviewed primary literature of any design related to disparities in FPRS was eligible for inclusion.

RESULTS

Of the 12283 unique abstracts identified, 215 studies underwent full-text review, and 108 remained for final review. The most frequently examined topics were cleft lip and palate (40.7%), facial trauma (29.6%), and gender affirmation (9.3%). There was limited coverage of other areas. Consideration of race/ethnicity (68.5%), socioeconomic status (65.7%), and gender/sex (40.7%) were most common. Social capital (0%), religion, occupation, and features of relationships were least discussed (0.01% each). The majority of studies were published after 2018 (59.2%) and were of nonprospective designs (95.4%). Most studies focused on disparity detection (80.6%) and few focused on understanding (13.9%) or reducing disparities (5.6%).

CONCLUSION

This study captures the existing literature on health disparities in FPRS. Studies are concentrated in a few areas of FPRS and are primarily in the detecting phase of public health research. Our review highlights several gaps and opportunities for future disparities-related focus.

Does Alcohol Use Influence Hospitalization Outcomes in Adults Suffering Craniomaxillofacial Fractures From Street Fighting?

Study Design

This retrospective cohort study utilized the National Inpatient Sample (NIS) database for the years 2016-2018. Incidences of street fighting were identified using the corresponding ICD-10 codes.

Objective

To determine whether alcohol use (measured by blood alcohol content (BAC)) in patients sustaining maxillofacial trauma from hand-to-hand fighting influence hospitalization outcomes.

Methods

The primary predictor variable was BAC stratified into six categories of increasing magnitude. The primary outcome variable was mean length of hospital stay (days). The secondary outcome variable was total hospital charges (US dollars).

Results

Our final sample consisted of 3038 craniomaxillofacial fractures. Each additional year in age added +$545 in hospital charges (P < .01). Non-elective admissions added $14 210 in hospital charges (P < .05). Patients admitted in 2018 experienced approximately $7537 more in hospital charges (P < .01). Le Fort fractures (+$61 921; P < .01), mandible fractures (+$13 227, P < .01), and skull base fractures (+$22 170; P < .05) were all independently associated with increased hospital charges. Skull base fractures added +7.6 days to the hospital stay (P < .01) and each additional year in patient age added +.1 days to the length of the hospital stay (P < .01).

Conclusions

BAC levels did not increase length of stay or hospitalization charges. Le Fort fractures, mandible fractures, and skull base fracture each independently increased hospital charges. This reflects the necessary care (ie, ICU) and treatment (ie, ORIF) of such fractures. Older adults and elderly patients are associated with increased length of stay and hospital charges-they are likely to struggle in navigating the healthcare system and face socioeconomic barriers to discharge.

Maxillofacial trauma in the gulf countries: a systematic review

PURPOSE

The objective of this review was to determine the prevalence, major causative factors and the most common sites of Maxillofacial Trauma in the Gulf Cooperation Council (GCC) Countries.

METHODS

All articles that were published in the English language in the databases such as Google Scholar, EBSCO, PubMed, NCBI, Medline, COCHRANE, ELSEVIER and SCOPUS were reviewed for MFT from GCC during the last 23 years.

RESULTS

A total of 19,151 patients (16,567 males and 2584 females) (86-14%) with an age range between 0 and 97 years were included in the study. In all of the Gulf countries males outnumber females in terms of maxillofacial injuries with a ratio of 6.4:1. The mandible was the most common site of trauma followed by the maxilla. Road Traffic Accidents (RTA) was the most common cause of injury in the GCC followed by falls.

CONCLUSION

Maxillofacial injuries are highly prevalent, distributed among the Gulf countries, and is mainly caused by RTAs especially among males who are highly prone to MFT in the gulf. The reasons are due to lack of road safety culture and weak enactment of traffic legislation, other possible factors include intrinsic car safety features, high speed driving and the amount/use of highways in these societies.

Trends in Operative Complex Middle and Upper Maxillofacial Trauma: A 17-Year Study

OBJECTIVES/HYPOTHESIS

Over 3 million incidents of facial trauma occur each year in the United States. This study aims to determine trends in operative middle and upper maxillofacial trauma in one of the largest US cities.

STUDY DESIGN

Retrospective case-control study.

METHODS

Retrospective chart review of all operative middle and upper maxillofacial trauma from July 1993 to July 2010 presenting to Los Angeles County Hospital, a Level I Trauma Center. Data included demographics, mechanism of injury, and fracture characteristics.

RESULTS

Analysis was performed for a total of 4,299 patients and 5,549 facial fractures. Mean patient age was 34.6, and most patients were male (88%). Between the two time periods (1993-2001 and 2002-2010), there was a 42% reduction in operative maxillofacial trauma (3,510 to 2,039). Orbital floor and zygomaticomaxillary complex fractures were the most prevalent types of fractures. Panfacial fractures demonstrated the largest reduction in number of fractures (325 to 5, P<0.01). Assault and motor vehicle accidents (MVA) were the two most common mechanisms of injury. Operative fractures due to MVAs decreased (390 to 214, P = .74), whereas fractures due to assault increased (749 to 800, P<0.01). Compared to adults, pediatric facial trauma (age < 18) were caused by a higher percentage of MVAs (27% vs. 13%), auto versus pedestrian (9% vs. 5%), and gunshot wounds (8% vs. 4%) (P<0.01).

CONCLUSIONS

Operative middle and upper maxillofacial trauma decreased over a 17-year period. Assault was the most significant mechanism of trauma overall. These trends suggest that focusing future prevention strategies on curtailing interpersonal violence may more effectively address the burden of facial trauma.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1985-1989, 2021.

Comparison of Maxillofacial Trauma Patterns in the Urban Versus Suburban Environment: A Pilot Study

Introduction

Assault appears to be the most frequent cause of facial fractures in certain urban trauma centers, possibly due to the ease of acquiring weapons and increasingly aggressive behavior. The objectives of this study were to identify specific demographic, socioeconomic, maxillofacial fracture, and assault patterns in urban versus suburban communities.

Methods

A retrospective chart review of patients who sustained maxillofacial fractures from August 2014 through August 2016 at one urban campus, Einstein Medical Center, Philadelphia, and two suburban campuses, Einstein Medical Center Montgomery and Elkins Park. The χ² testing was used to compare the categorical variables between the 2 groups.

Results

A total of 259 maxillofacial trauma patients were identified, with 204 (79%) in the urban and 55 (21%) in the suburban environment. Patients in the urban population were more likely to be African American (70% vs 33%) and Hispanic (15% vs 6%) but less likely to be Caucasian (12% vs 55%, P < .0001). Urban patients were more likely to be single (70% vs 47%, P < .01), unemployed (64% vs 44%, P < .001), and receive Medicaid coverage (58% vs 26%, P < .001). Urban patients were more likely to be victims of assault (63% vs 44%), whereas suburban patients were more likely to sustain accidental injuries (16% vs 2%, P < .0001). Urban victims were more likely to be assaulted with an object (30% vs 12%) or gun (7% vs 0%, P = .05).

Conclusion

Maxillofacial trauma patterns were shown to be significantly different in the urban versus suburban environment.

A Cross-sectional Study of the Association between Homelessness and Facial Fractures

Background:

Little is known about the risk factors for facial fractures among homeless patients. We investigated the association between homelessness, mechanism of injury, and type of facial fracture in patients treated at an urban trauma center.

Methods:

Data for 2,221 adults with facial fractures were obtained retrospectively from a standardized registry of trauma patients at Zuckerberg San Francisco General Hospital from 2011 to 2016. Associations between homelessness and mechanism of injury, facial fracture type, and surgical repair type were evaluated with multivariate multinomial logistic regression analysis.

Results:

Among 2,221 patients with facial fractures, 12% were homeless and, compared with housed patients, more likely to be male, black, and test positive for drug and alcohol use (all P < 0.0001). They had lower injury severity scores but longer hospital stays and were more likely to be discharged to the community than to a rehabilitation facility (all P < 0.0001). After adjusting for confounding variables, homeless patients with facial fractures were nearly 3-fold more likely to have been assaulted than housed patients (OR = 2.8, 95% CI = 1.9–4.1, P < 0.0001) and twice as likely to have mandible fractures (OR = 2.0, 95% CI = 1.3–3.0, P = 0.0030) and to have surgery for these fractures (OR = 2.1, 95% CI = 1.2–3.7, P = 0.0110).

Conclusions:

Our novel results demonstrate that homeless patients with facial fractures are at much higher risk than the general population for being assaulted, suffering mandible fractures, and requiring surgery for these fractures. Further investigations could guide identification, treatment, and prevention efforts.

Comparing Urban Maxillofacial Trauma Patterns to the National Trauma Data Bank©

OBJECTIVES

We aimed to determine whether certain maxillofacial fracture patterns and injury mechanisms were more prevalent in an urban environment. In addition, we aimed to determine if maxillofacial trauma incidence correlated with income.

METHODS

Data was collected from Einstein Healthcare Network and Temple University Health System. These data were compared to the 2016 National Trauma Data Bank© (NTDB©) using chi-square analysis. Multivariate analysis was used to identify correlations between demographic variables and fracture patterns. Sociodemographic data was further characterized utilizing neighborhood mapping.

RESULTS

A total of 252 patients from our urban campuses and 14 447 patients from the NTDB© were identified with facial fractures. Maxillofacial trauma patients in the urban population were more likely to be minorities and less likely to be Caucasian compared to the NTDB© (P < .001). Patients in the urban setting were more likely to sustain mandibular and orbital fractures, and less likely to sustain maxillary fractures and multiple fractures (P < .001). Urban maxillofacial trauma patients were more likely to sustain assault and sporting injuries, and less likely to sustain injuries from motor vehicle accidents and self-harm (P < .001).

CONCLUSIONS

Maxillofacial trauma patterns and injury mechanisms were shown to be significantly different in an urban environment as compared to national data.

Inter personal violence-related facial injuries: a 10-year survey

Introduction: Interpersonal violence (IPV) has emerged as a worldwide health problem affecting predominantly the face. Patients and methods: This study reports the characteristics of violence, victims and injuries in IPV-related facial injuries patients, in a 10-year survey, in a tertiary hospital of Burkina Faso. Results: Patients’ age ranged from 11 to 75 years (mean 31 years) and 58.2% of the patients were aged between 20 and 39 years. There were 74 males and females 24 giving a male-to-female ratio of 3.1:1. The circumstances of injuries were brawls (80.6%) consisting mostly in facial blows, and hold-ups (19.4%). Fractures involving predominantly the mandible or the zygomatic complex were the most common injury, accounting for 53.2%. Soft tissues injuries accounted for 37.2% and dental trauma for 9.2%. In 27.5% of the patients, extra facial injuries were encountered, dominated by cerebral trauma and limb fractures. Conclusion: In this study, IPV-related facial injuries are mostly mandibular or zygomatic fractures in young and males adults involved in brawls. These findings command strategies for prevention of violence in this specific group.

Meta Analysis of Etiology and its Clinical and Radiological Correlation in Cases of Craniomaxillofacial Trauma

AIM

The present study was planned to investigate the etiology of injuries and to analyze correlation between clinical and radiological findings in cases of craniomaxillofacial trauma.

STUDY DESIGN

An 18 months cross-sectional study was done and 325 patients with maxillofacial fractures were analyzed from January 2013 to June 2014 who reported to the department of oral and maxillofacial surgery, Aligarh, Uttar Pradesh. Data was recorded in a preformed case sheet which included: patient's demographic data, cause of injury, type of injury, treatment plan.

RESULTS

Out of the 325 patients, 74.4 % were males with a male: female ratio of 2.91:1. The 21-30 year age group was found to be maximum. Road traffic accidents accounted for 71.3 %, followed by fall from height (19 %) and assault (9.5 %). Most commonly involved vehicles were two wheelers followed by public transport. Mandibular fractures (65 %) were most prevalent, followed by zygomaticomaxillary complex (44.27 %), parietal bone (48 %) and orbital fractures (21.3 %). Thirty-seven fractures (7.14 %) were missed clinically which were confirmed later by radiographic technique. Maximum were in cranium region (57 %) followed by mandible (27 %), mid face region (16.21 %). Thirty-three fractures (6.37 %) were overestimated or suspected clinically which could not be confirmed by radiographic technique. Maximum were in mandible (48.5 %) followed by mid face (36.33 %) and cranium (15.15 %).

CONCLUSION

The idea behind this article is to analyze the various trends and affecting factors and correlation between clinical and radiological findings. A better understanding of the above said would help in future treatment planning and management of facial injuries.

Epidemiology and resource utilization in pediatric facial fractures

BACKGROUND

Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures.

METHODS

Using the 2000-2009 Kids' Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes.

RESULTS

Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges.

CONCLUSIONS

There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.

Analysis of radiographically confirmed blunt-mechanism facial fractures

Facial fractures resulting from blunt-mechanism trauma, although common, have been infrequently evaluated in large studies that do not include confirmation of fractures based on author review of available patient radiographic studies. An 8-year review (1998-2006) of the R Adams Cowley Shock Trauma Registry was performed with institutional review board approval. Patients diagnosed with blunt-mechanism facial fractures were identified by the International Classification of Diseases, Ninth Revision (ICD-9) codes and their facial fractures confirmed by author review of computed tomographic scans. Individual fractures were classified and grouped according to the facial thirds. Intra- and interreader variability was calculated, and confirmed fracture patterns were compared to fracture patterns listed by ICD-9 codes. Concomitant injuries and demographic data were additionally evaluated. Four thousand three hundred ninety-eight patients with 8127 fractures were identified. Intra- and interreader variability was 2% and 7%, respectively. ICD-9 coding misdiagnosed 12.5% of all fractures. Eighty-two percent of patients sustained associated injuries, including basilar skull fractures (7.6%) and cervical spine fractures (6.6%). 1.1% had at least one fracture in each facial third (panfacial fracture pattern). Significant relationships were found between demographic parameters, concomitant injuries, specific fractures, and fracture patterns. Studies investigating facial fractures should report fracture patterns confirmed by author review of available radiographic imaging. Large retrospective data sets containing confirmed fractures and capable of addressing rare fracture patterns can be compiled with low inter- and intrauser variability, and are useful for generating mechanistic hypotheses suitable for evaluation in prospective series or by directed biomechanical studies.

Effect of clenching on biomechanical response of human mandible and temporomandibular joint to traumatic force analyzed by finite element method

Purpose: The purpose of the present study was to analyze the effect of clenching on the biomechanical response of human mandible and temporomandibular joint (TMJ) to traumatic force by the finite element (FE) method. Material and Methods: FE models of the mandible and the TMJ in resting and clenching positions were prepared. Distribution and magnitude of von Mises stress were analyzed by applying force as a point load in the symphyseal, canine, body and angle regions of the mandible. In addition, strain energy density (SED) at the articular disc and in posterior connective tissue of TMJ was analyzed. Results: In the resting position, von Mises stress was mainly concentrated at the condylar neck and in the retromolar region of the mandible. In the clenching position, the stress at the condylar neck decreased in all loadings. The stress in the retromolar region similary decreased in the symphyseal, canine and body loading, respectively; however, higher stress was observed in the retromolar region on the loading side in the angle loading. High SED was generated at the articular disc and in posterior connective tissues of TMJ in the resting position. The SED in these tissues decreased in all loadings in the clenching position. Conclusions: Clenching generally reduces stress at the condylar neck and in the retromolar region of the mandible, and strain energy at the articular disc and in posterior connective tissue of TMJ by traumatic forces on the mandible; however, clenching induces greater stress in the retromolar region on the loading side by traumatic force to the angle region.

Key words:Mandibular, temporomandibular joint, traumatic force, clenching, finite element analysis.

Fractures of angle of mandible - A retrospective study

AIMS

This retrospective study was done to evaluate the efficacy of single miniplate osteosynthesis at superior border of angle of mandible.

MATERIAL AND METHODS

In this study 50 patients were treated by single miniplate osteosynthesis according to Champy's principle. Bite force generated was used as a parameter for judging the efficacy of internal fixation. In this article we present our experience over the years in the management of the fractures of angle of mandible based on this model.

RESULTS

Most patients were of 21-30 yrs of age with unilateral angle fracture of mandible except one patient who had isolated bilateral angle fracture. The patients were treated successfully according to Champy's principle of osteosynthesis. There was a progressive improvement in the bite force generated after osteosynthesis.

CONCLUSIONS

The angle of the mandible is an anatomically weak and an area susceptible to fracture. The presence of an impacted or partially erupted third molar tooth further weakens it. Angle of mandible is the most common site for fracture however, bilateral angle fracture is very rare and uncommon. Osteosynthesis according to Champy's model led to an early functional improvement as demonstrated by the bite force generated.

Factors influencing the incidence of maxillofacial fractures

PURPOSE

Maxillofacial injuries occur in a significant proportion of trauma patients. Trauma causes considerable economic expense due to procedural costs, the time a patient is off work, and the associated loss of income. For these reasons, it is an important health and economic issue. The aim of this study is to discuss the factors that may influence the incidence of maxillofacial fractures. As it is necessary to determine trends to help guide the development of new methods of injury prevention, preventative measures are also discussed.

METHODS

An electronic search was undertaken in March 2011, including articles published between 1980 and 2011 with the terms "facial fractures" and "maxillofacial fractures" in the title. The texts of epidemiological studies were reviewed in order to identify factors that may influence the incidence of maxillofacial fractures.

RESULTS

From the selected articles, ten factors were identified: age, gender, geographic region and cultural aspects, socioeconomic status, temporal and climatic influence, use of alcohol and drugs, compliance with road traffic legislation, domestic violence, osteoporosis, and etiology of the maxillofacial trauma.

CONCLUSIONS

Care of injured patients should include not only management of the acute phase, but also combine preventive programs and interventional programs aimed at reducing the incidence of maxillofacial fractures. Therefore, there is a need to ensure strict compliance of traffic rules and regulations, implement improvement in automotive safety devices, organize prevention programs to minimize assaults, implement school education in alcohol abuse and handling potentially hostile situations (especially for men), improve protection during sporting activities, and legislate wearing of protective headgear in workers. Preventive strategies remain the cheapest way to reduce direct and indirect costs of the sequelae of trauma. Societal attitudes and behaviors must be modified before a significant reduction in the incidence of maxillofacial fractures will be seen.

Pediatric craniofacial fractures due to violence: comparing violent and nonviolent mechanisms of injury

BACKGROUND

This study examines the epidemiologic data of pediatric craniofacial fractures secondary to violence, comparing these data to craniofacial fractures sustained from all other causes.

METHODS

A retrospective review was completed on all patients who presented to the emergency department of a major urban children's hospital from 2000 to 2005 with a craniofacial fracture. Data were compared between patients with fractures due to violent and nonviolent mechanisms. Socioeconomic analysis was performed using Geographic Information System mapping and 2000 US Census data by postal code.

RESULTS

One thousand five hundred twenty-eight patients were diagnosed with skull and/or facial fractures. Isolated skull fractures were excluded, leaving 793 patients in the study. Ninety-eight children were injured due to violence, and 695 were injured from a nonviolent cause. Patients with violence-related fractures were more likely to be older, male, and nonwhite and live in a socioeconomically depressed area. A greater number of patients with violence-related injuries sustained nasal and mandible angle fractures, whereas more patients with non-violence-related injuries sustained skull and orbital fractures. Those with violence-related craniofacial fractures had a lower percentage of associated multiorgan system injuries and a lower rate of hospital admissions and intensive care unit admissions. The rate of open reduction and internal fixation for craniofacial fractures was similar in both groups.

CONCLUSIONS

Patients with violence-related fractures had fewer associated serious injuries and lower morbidity and lived in a more socioeconomically depressed area. The information gained from this descriptive study improves our ability to characterize this population of pediatric patients and to identify the associated constellation of injuries in such fractures.

Violence-related facial trauma: analysis of multidetector computed tomography findings of 727 patients

OBJECTIVES

The multidetector CT (MDCT) findings of facial trauma in victims of interpersonal violence were assessed.

METHODS

All MDCT requests for suspected facial injury during a 62 month period were retrieved; 727 cases met the inclusion criteria. Images were interpreted by two researchers by consensus.

RESULTS

Of the 727 patients (aged 15-86 years old, mean 37), 583 (80.2%) were male and 144 (19.8%) female. Of all the patients, 74% had a fracture, and of these 44% had multiple non-contiguous fractures.

CONCLUSIONS

Violence is a very common cause of facial injury. Nasal and orbital fractures predominate. Males are more often involved; they are younger, sustain fractures more often and significantly more often present with high-energy fracture patterns. LeFort fractures are often unilateral or asymmetrical, and are frequently accompanied by other, clinically significant fractures. Up to 25% of patients with fractures do not have paranasal sinus effusions.

An examination of posttraumatic, postsurgical orbital deformities: conclusions drawn for improvement of primary treatment

A retrospective analysis was carried out on the records of 317 patients operated on by the senior author (S.A.W.) for orbital fractures between 1975 and 2007. Two hundred forty of the patients had been previously operated on elsewhere and required further correction (posttraumatic, postsurgical orbital deformity). A smaller group of patients (n = 77) were operated on primarily. The two groups were not, of course, similar, because the posttraumatic, postsurgical orbital deformity group had been operated on by a variety of surgeons with varying levels of experience and ability, and the group of patients operated on primarily had a larger percentage of fractures in the pediatric age group, because of the practice being partially based in a children's hospital, and a larger percentage of severe, compound orbital injuries, because of statewide referrals. Nevertheless, a number of causes for reoperation seen in the posttraumatic, postsurgical orbital deformity group were not seen in the primarily operated group. These included lower eyelid retraction attributable to use of the subciliary incision, displacement and extrusion of alloplastic materials, and fixation of fractures in a nonreduced position. These differences validate, in the authors' opinion, the application of the basic principles of craniofacial reconstruction set forth by Paul Tessier, listed in the text, to both the primary and secondary treatment of posttraumatic orbital deformities.

Incidence and characterization of unifocal mandible fractures on CT

BACKGROUND AND PURPOSE

Conventional thinking among radiologists is that the mandible acts as a closed "ring" that needs to fracture at 2 points, though the frequency of multiple mandible fractures has been reported to be only as high as 67%. However, many of these studies did not use CT to confirm the presence of suggested fractures and excluded nondisplaced fractures. The purpose of this study was to determine the incidence of unifocal mandibular fractures on the basis of detection with dedicated facial bone CT scans and to characterize these fractures.

MATERIALS AND METHODS

We retrospectively reviewed the imaging reports of patients during a 3-year period to identify those who had mandible fractures documented on dedicated facial bone CT scans. The incidence of unifocal fractures was determined, the unifocal fractures were further subcategorized, and any derangements of the temporomandibular joints were also evaluated.

RESULTS

One hundred two patients met the inclusion criteria. The incidence of unifocal mandible fractures was 42% (43/102). Three unifocal fracture patterns identified were the following: simple fractures (25/42, 58%), comminuted fractures (11/42, 26%), and fractures associated with condylar subluxations (7/42, 16%). Most fractures had none to mild displacement or distraction.

CONCLUSION

Unifocal mandible fractures occur with greater frequency than anticipated by most radiologists. This may be due to the somewhat dynamic nature of the mandibular "ring," which includes the temporomandibular joints, though joint derangements evident on CT occur in the minority of cases.

A 3-year survey of assault-related maxillofacial fractures in central Switzerland

AIM

The aim of this study was to analyse the character of assault-related facial fractures in central Switzerland and to compare their prevalence with the data presented in similar reports from other countries.

MATERIAL

The present study comprised 65 patients with assault-related maxillofacial fractures treated in the Department of Cranio-Maxillofacial Surgery, University Hospital of Bern between 2000 and 2002.

METHODS

The mechanism, the causes of the injuries and the location of the fractures were analysed by reviewing emergency and hospital records. Concomitant injuries were also studied.

RESULTS

The mean age of the patients was 33 years with the largest group being below 25 years. The male-to-female ratio was 56:9. The most common causes of assault-related injuries were fights, most frequently facial blows, accounting for 92.5% of all patients. Seventy-six per cent of the fractures occurred in the middle and upper facial skeleton with a predominance of 2:1 for the left side. In 39 patients (60%) surgery was necessary, with a mean hospital stay of 3.3 days. Thirty-five patients (54%) had concomitant injuries. Alcohol and drug abuse was found in 15 patients (23%).

CONCLUSION

It seems that mostly young men suffer assault-related maxillofacial injuries. A contributing factor to the increased disposition for violence could be alcohol and drug abuse. Therefore, national prevention programmes for alcohol or drug abuse and addiction might have a positive effect on reducing the incidence of assault-related maxillofacial injuries.

Injury severity: role of alcohol, substance use and risk-taking

OBJECTIVE

The objective of the present study was to quantify the relationship between acute alcohol consumption and injury severity.

METHODS

A cross-sectional study was conducted at the Gold Coast Hospital, Gold Coast, Queensland, Australia between October 2000 and October 2001. Data were collected from a systematic sample of patients greater than 15 years of age who presented to the ED for treatment of an injury sustained less than 24 h prior to presentation. Study participants were interviewed face to face on-site. Information obtained included: demographics details; situational variables relative to time of injury (i.e. location, activity and companions at time of injury); self-reported alcohol consumption in the 6 and 24 h prior to time of injury; usual alcohol consumption patterns; self-reported substance use in the 6 and 24 h prior to time of injury; and risk-taking behaviour. Injury severity was coded from patient medical records using the New Injury Severity Score.

RESULTS

Of 789 eligible patients presenting during the study periods, 593 were interviewed (75.2%). Patients who reported drinking above low-risk levels (odds ratio [OR] = 3.35; 95% confidence interval [CI] 1.2-9.6) or who drank beer (OR = 3.54; 95% CI 1.1-11.1) in 6 h prior to injury were significantly more likely to sustain serious than minor injury. Drinking setting and usual drinking patterns were not significantly associated with injury severity, either in crude analyses, or after adjusting for relevant variables.

CONCLUSION

The results of the present study support the conclusion that among injured patients who presented for treatment at a large metropolitan ED, although acute alcohol consumption does not appear to be associated with minor or moderate injury, there is some evidence to suggest that acute alcohol consumption is associated with serious injury.

Continuity of interpersonal violence between Nubian communities

Modern communities affiliated with the same culture have been shown to experience comparable levels of interpersonal violence, no matter what their size. It was hypothesized that a similar relationship would exist among ancient rural and urban people, but that accident-related trauma may be more prominent among rural dwellers due to their activity base. Through an analysis of antemortem trauma, this investigation contrasted the injury profile of Nubian adult villagers (N = 55) from the Kerma period (2500-1750 BC) to that of their urban neighbors (N = 223) at Kerma (2050-1500 BC). The injury pattern associated with interpersonal violence (cranial injury, direct-force ulna fractures, and multiple injuries) was similar between the two samples, as hypothesized. The rural group sustained significantly more nonviolence-related injuries that suggested occupational or environmental influences. The more severe cranial injuries observed among urban people are attributed to a preference for more lethal hand-wielded objects that may have accompanied increasing local tensions and incursions into Egypt during the 17th Dynasty.

Fracture Patterns and Bone Healing in Recurrent Mandibular Fractures: A Clinical Study of 13 Patients

BACKGROUND

Recurrent fractures of the previously treated fractured mandible are rare.

METHODS

In this retrospective study, 13 cases of repeated mandibular fractures were evaluated according to age, sex, cause, fracture localizations and patterns, treatment modalities, and complications.

RESULTS

All of the patients were men, with a mean age of 27.5 years and 32 years for the first and the subsequent fractures, respectively. The mean time interval between fractures was 4.3 years. In 10 cases, the cause for the second fracture was an assault, with 90 percent related to alcohol intake. Angle, body, and parasymphysis region of the mandible were the most common sites to be involved in the first occasion. In 10 cases, an internal rigid fixation procedure was performed for the treatment. In the recurrent injuries, none of the fractures occurred at exactly the same anatomical site. Fractures were either in the neighboring side or the contralateral side of the previously healed area of mandible. On the second occasion, angle fractures were common and body and subcondylar fracture rates increased. At second presentation, the complication rate increased from 23.1 percent to 53.8 percent and most commonly involving malocclusion.

CONCLUSIONS

This study showed that assault is the major etiologic factor for recurrent mandible fractures and that these fractures occur in different locations from the original injury. They necessitate a cautious approach for the prevention of unfavorable outcomes. Further retrospective clinical and experimental studies are necessary to elucidate the fracture patterns and bone-healing quality of these recurrent mandible fractures.

Treatment of mandibular angle fractures with a matrix miniplate: a preliminary report

Mandibular angle fractures are technically challenging, and a spectrum of techniques for treatment of these fractures has been proposed in the literature. Currently, fixation with one or two miniplates has become a widely accepted method of providing internal fixation and eliminating the need for postoperative maxillomandibular fixation. In this study, the utility of a single 2.0-mm matrix miniplate for mandibular angle fracture management was examined. In a laboratory biomechanical analysis, the overall stability of the single 2.0-mm matrix miniplate compared favorably with two 2.0-mm miniplates in a simulated fracture setting. The matrix miniplate demonstrated an overall better intrinsic stability, more resistance to out-of-plane fracture movement, and a higher load tolerance when motion out-of-plane was challenged. Clinically, the matrix miniplate performed well. In a series of 22 consecutive patients, there were no cases of nonunion, malunion, or plate failure. Two patients developed infection that was managed in both cases by drainage with maintenance of the miniplate. Both went on to full union. These results compare very favorably to previously published series using one or two miniplates.

Ballistic Impact to the Forehead, Zygoma, and Mandible: Comparison of Human and Frangible Dummy Face Biomechanics

BACKGROUND

Currently, there is a greater use of nonlethal force in law enforcement and military operations. Because facial injuries have been observed, there is a need to understand the human response to ballistic impacts involving various regions of the face. This study aimed to establish blunt ballistic response corridors for high-speed, low-mass facial impacts to the forehead, zygoma, and mandible, and to determine how these responses compare with those of the frangible Hybrid III headform. Correlation of the human and dummy responses allows injury risk assessment for munitions used in the field.

METHODS

Facial impacts to the forehead, zygoma, and mandible of six cadavers at 42 +/- 10 m/sec were conducted using a 25- to 35-g projectile 37 mm in diameter that was instrumented with an accelerometer to determine impact force. High-speed video analysis determined penetration of the projectile, and autopsy determined the facial fractures. Force and deflection were normalized for the 50% tile response, and corridors were determined for blunt ballistic impacts. Similar tests were conducted on the frangible face of the Hybrid III dummy.

RESULTS

Peak normalized force of 3.5 +/- 0.9 kN on the forehead and 3.0 +/- 1.0 kN on the mandible did not result in fractures, whereas an impact force of 2.3 +/- 0.5 kN on the zygoma caused anterior maxilla fractures. The frangible Hybrid III face developed similar force levels, but with less penetration of the projectile. Its stiffness was 43% greater than that of the cadaver.

CONCLUSIONS

Higher impact force can be tolerated on the forehead and mandible than on the zygoma. Normalized force-deflection and force-time corridors were established for the human response. The frangible Hybrid III face is an effective surrogate for assessing ballistic injury risks, but greater compliance would make it more biofidelic. Initial human tolerance levels of 6.0 kN for the forehead, 1.6 kN for the zygoma, and 1.9 kN for the mandible have been established for ballistic impacts to the face.

Socioeconomic variation in injury in children and older people: a population based study

OBJECTIVES

To compare hospital admission rates for all causes and specific causes of injury in children and the elderly by a measure of economic deprivation.

STUDY DESIGN

All emergency admissions for Welsh residents from 1997-99 were located to one of 865 electoral tracts, which were grouped into fifths using a measure of socioeconomic deprivation. Standardised admission rates for all ages and 0-14, 15-75, and 75+ year groups for each quintile were calculated with 95% confidence intervals.

RESULTS

There were 90 935 admissions in a population of 2.84 million yielding a crude admission rate of 1601/100 000/year and a standardised rate of 1493/100 000. The ratio of admissions in deprived and affluent areas varied with category of injury and age group. In general, socioeconomic variations in injury rates were much smaller in older people than in children with the exception of pedestrian related injuries where the rates were similar. The largest variations were for injuries sustained in assaults or self inflicted.

CONCLUSIONS

The relationship between socioeconomic position and injury varies by cause and age group. This should be considered when developing area based preventive interventions or monitoring the effectiveness of policies to reduce inequalities in injury occurrence.

Survey of trauma patients requiring maxillofacial intervention, ages 56 to 91 years, with length of stay analysis

PURPOSE

The purpose of this study was to analyze trauma patients, ages 55 and older, sustaining multiple injuries including maxillofacial trauma. Factors influencing length of intensive care unit stay (ICUS) and length of total hospital stay were delineated and examined to determine if specific causes of increased length of stay could be elucidated, and, once known, if these causes could translate into recommendations tailored to the oral and maxillofacial surgery trauma practice.

PATIENTS AND METHODS

One hundred ninety-six patients, 55 years of age or older, who received either consultation alone, or consultation with surgical treatment, by oral and maxillofacial surgeons, from January 1991 to August 1998 were included in this study. Variables of interest included location of traumatic event, mechanism of injury, patient age and gender, comorbidities on presentation, Injury Severity Score (ISS), specific injuries incurred, ICUS, length of hospital stay (LOS), surgical interventions, and disposition.

RESULTS

Complications were the statistically significant factor determining length of ICU stay. ICUS, complications incurred, and ISS were the important predictors of total LOS. The significant complications affecting LOS were infectious, respiratory, and hematologic complications.

CONCLUSION

The number of complications the patient incurs after an injury can predict length of ICUS. Length of ICUS, ISS, and number of complications incurred were the strongest predictors for total length of hospital stay. Other variables, including age, gender, living or dead, blunt versus penetrating injury, ISS, fracture site (skull, midface, or lower face), and comorbidities on presentation were not statistically significant in this patient population. Infectious, respiratory, and hematologic complications were the complications most closely correlated with increasing length of ICUS and total hospital stay.

5196 mandible fractures among 4381 active duty army soldiers, 1980 to 1998

OBJECTIVE

We present the frequencies of various types of mandibular fractures along with associated mechanisms and injuries.

METHODS

Retrospective analysis of 5196 mandible fractures in 4381 patients extracted from the Total Army Injury and Health Outcomes Database (TAIHOD), a comprehensive database developed by the U.S. Army Research Institute of Environmental Medicine (USARIEM) that links population data to all hospitalizations among active duty army soldiers. The database is based on the ICD-9 CM coding system.

RESULTS

We found the following frequencies for specific mandible fracture locations: angle 35.6%, symphysis 20.1%, subcondylar 14.2%, body 12.7%, condylar process 9.1%, ramus 4.5%, alveolar border 2.7%, and coronoid process 1%. The mechanisms of injury were separated into seven categories. Fighting accounts for 36.2%, automobile accidents for 18.6%, athletics for 13.6%, falls for 9.7%, motorcycle accidents for 3.1%, other land transport accidents for 3%, and miscellaneous causes for 15.8%. A few fracture locations appear to be associated with specific mechanisms. Of 82 alveolar border fractures with known mechanisms, 37% resulted from automobile accidents. Of 1094 angle fractures with known mechanisms, 48.6% resulted from fighting. Our data show that the majority of fractures were isolated to one location. Only one fracture was recorded for 70.6%, 29.2% have two fractures recorded, 0.2% have three or more fractures recorded. Associated injuries were common and include facial lacerations 1236 (28.2%), non-mandible facial bone fractures 733 (16.7%), intracranial injury 403(9.2%), internal injuries 229 (5.2%), fractures of the upper limb 295 (6.7%), fractures of the lower extremity 302 (6.9%), and cervical fractures 34 (0.8%).

CONCLUSIONS

The mechanism of injury is important in determining the most likely resultant mandible fracture in the case of angle of mandible and alveolar ridge fractures. The clinician should maintain a high level of suspicion for associated injuries that occur more than one fourth of the time and even more frequently in motor vehicle accident victims. Associated intracranial injury is particularly important to rule out. Associated facial fractures, intracranial injury, internal injuries, and extremity injuries are all more common than cervical fractures.

Orbital fractures due to domestic violence: an epidemiologic study

Domestic violence is an important cause of orbital fractures in women. Physicians who treat patients with orbital fractures may not suspect this mechanism of injury. The purpose of this study was to assess the association between domestic violence and orbital fractures. A medical center-based case-control study with matching on age and site of admission was done. Medical center databases were searched using ICD-9 codes to identify all cases of orbital fractures encountered during a three-year period. Medical records of female patients age 13 and older were reviewed along with those of age, gender and site of admission matched controls. A stratified exact test was employed to test the association between domestic violence and orbital fracture. Among 41 adult female cases with orbital fractures treated at our medical center, three (7.3%) reported domestic violence compared to zero among the matched controls (p = 0.037). We believe that domestic violence may be under-reported in both orbital fracture cases and controls. This may result in an underestimate of the orbital fracture versus domestic violence association. Domestic violence is a serious women's health and societal problem. Domestic violence may have a variety of presentations, including illnesses and injuries. Orbital fracture is an identifiable manifestation of domestic violence. Domestic violence is more likely to be detected in adult female hospital patients with orbital fracture than in matched controls with any other diagnosis. Physicians who treat patients with orbital fractures should be familiar with this mechanism of injury.

Nasal and Nasoethmoidal-Orbital Fractures: A Continuum of Injury

The unilateral nasoethmoid orbital (NOE) fracture is frequently misdiagnosed. This fracture is independent of the clinically obvious NOE fracture and has alternately been referred to as complex nasal, minimally displaced, occult or greenstick NOE fracture. Failure to identify and treat these injuries at initial presentation results in undesirable aesthetic and functional consequences that are difficult to repair secondarily. Three patients who presented with nasal fractures complicated by minimally displaced fractures of the medial orbital wall were reviewed retrospectively. These injuries were successfully diagnosed and treated after their examining physicians failed to appreciate the injury on the initial evaluation. Complex nasal injuries with fracture extensions to the NOE are often missed by the examining physician. These injuries should benefit from a high index of suspicion and be evaluated with axial and coronal computed tomographic imaging. Acute treatment with appropriate exposure, open reduction, internal fixation and bone grafting is most compatible with a successful outcome.

Epidemiology of facial injury in female blunt assault trauma cases

BACKGROUND

Etiology of trauma in the female population differs from that of the male population. To date, domestic violence has been researched extensively, but little has been published about the epidemiology of facial injury in the female population.

OBJECTIVES

To analyze the differences in the circumstances under which males and females are injured, to identify gender-specific patterns of injury, and to assess whether differences in the demographics, health status, and drug-use profile exist between female and male assault cases and whether these factors lead to a difference in outcome.

METHODS

A cohort of 91 female assault cases was compared with a control group of 706 males with similar injuries resulting from blunt assault trauma. Information was gathered by retrospective review of 797 consecutive cases requiring admission for facial injuries resulting from blunt assault trauma. Fisher exact, chi 2, and t tests were used to assess statistically significant differences between the male and female cohorts.

RESULTS

The female cohort comprised 12% of all cases admitted for blunt assault facial trauma. One third of female blunt assault facial trauma patients were subjects of domestic violence. Statistically significant differences were found between males and females for the type of assault (rape, domestic violence, altercation, etc) with P < .0001. Females were more likely to be admitted with soft tissue injury only but no fracture (P < .05), less likely to be assaulted with a weapon, and unlikely to be involved in an altercation, gang violence, arrest, or robbery. Females were also less likely than males to be injured while intoxicated (P < .05). Incidence of specific injury patterns and outcomes, however, were similar between the 2 groups.

CONCLUSION

The present data support the hypothesis that the female blunt assault facial trauma population represents a distinct epidemiological entity, with significant differences in the circumstances of injury, mechanism of assault, and role of intoxication in the incidence of injury. The prevalence of facial trauma in female assault cases makes it critical for the facial plastic surgeon to be vigilant in the evaluation and treatment of these patients.

Direct bonded orthodontic brackets for maxillomandibular fixation

OBJECTIVES/HYPOTHESIS

Mandibular fracture treatment often includes arch bar maxillomandibular fixation (MMF), either alone or in combination with open reduction/internal fixation (ORIF) techniques. The glove perforation rate associated with arch bar placement, the incidence of blood-borne pathogen positivity in facial fracture patients, and the injurious effects of arch bars on dental enamel and gingiva have prompted the development of safer alternatives to arch bar MMF. This study evaluates the efficacy, ease of use, and safety profile of one such alternative: orthodontic direct bonded bracket fixation (MMF/DBB).

STUDY DESIGN

Prospective study of consecutive mandible fracture patients treated with MMF/DBB.

METHODS

Thirty-two patients with mandibular fractures were evaluated from January 1994 to July 1997. Fourteen were appropriate for treatment with MMF/DBB (12 men and two woman; mean age, 24.6+/-7.2 y; range, 16-42 y). Fracture sites included symphysis, angle, condylar neck, coronoid, and body. Nine patients underwent MMF/DBB alone; five underwent MMF/DBB with subsequent ORIF.

RESULTS

No infection, malocclusion, malunion/nonunion, or enamel/ gingiva injury occurred. Mean follow-up was 6 months (range, 1-12 mo). Oral hygiene with MMF/DBB was superior to historical controls using arch bars.

CONCLUSIONS

MMF/DBB can serve as the single treatment method with satisfactory results in patients with favorable, less complicated mandible fractures, although with increased experience, we have treated several more complex cases with MMF/DBB alone. In cases necessitating ORIF, MMF/DBB can be performed preoperatively to align fracture segments and reestablish occlusion. This facilitates placement of osteosynthesis plates and reduces ORIF operative time. MMF/DBB is an economical, safe technique that minimizes blood-borne-pathogen risk to the operative team, eliminates periodontal injury, facilitates postoperative dental hygiene, and is painless to apply and remove.