trauma is one of the leading causes of death among people under 40 years of age1 .
maxillofacial injuries are one of the most common injuries associated with other injuries and adult males are the most common victims .
road traffic accidents ( rta ) are the major cause of maxillofacial injuries in developing countries2 .
the main aim of this retrospective study was to evaluate the prevalence of maxillofacial injury , etiology , type of injury , site of maxillofacial fractures , and their management .
the records of maxillofacial injury patients from may 2014 to november 2015 who reported to the department of dentistry , esic medical college and post graduate institute of medical sciences and research ( pgimsr ) , chennai in india were retrieved .
head injury patients with brain involvement who required neural intervention and mortal cases were excluded .
the records of 267 patients between the ages of five to seventy - five years were retrospectively analyzed .
data including age , gender , mode of injury , etiology , anatomical fracture site , consciousness status , alcohol abuse at the time of injury , and treatment rendered were extracted .
the etiology of injury was categorized into four main categories : ( 1 ) rta involving automobiles , motorcycles and bicycles , including drivers , pillion riders , passengers , and pedestrians ; ( 2 ) fall(s ) from heights or while playing or due to systemic illness like epilepsy ; ( 3 ) assaults or interpersonal violence ; and ( 4 ) sports injuries and other injuries . fractures were grouped and coded according to international classification of diseases ( icd)-10 : s02.4 , zygomatic complex ( zmc ) fracture involving malar bone and maxilla ; s02.3 , orbital floor fracture ; s02 , fractures involving facial and skull bones ; s02.6 , mandible fractures ( which includes condyle , ramus , angle , body of the mandible , parasymphysis , symphysis ) ; s02.5 , tooth fracture ; and s02.2 , nasal bone fractures . statistical analysis using spss version 16.0 ( spss inc .
study outcomes were measured using percentages , the mean , standard deviation and tests of proportion as appropriate .
the prevalence of injury in a particular age group and gender distribution , etiology , type of fracture , management and influence of alcohol were analyzed . for comparison ,
the study was approved by the institutional review board of esic medical college and pgimsr ( no .
out of 267 case records in the age group between 5 to 75 years , maxillofacial fractures accounted for 93.3% of total injuries .
the mean age and standard deviation of the patients was 35.011.8 years , with a minimum age of 5 years and a maximum age of 75 years .
gender distribution shows that 74.5% ( 199/267 ) of subjects were male and 25.5% ( 68/267 ) were female , with a male to female ratio of 3:1 .
table 1 ) the test of proportion for males and females shows that there was a statistically significantly higher proportion of males involved in accident and injuries ( p<0.001 ) .
( 1 ) the report shows that the most common cause for maxillofacial injury was rta , accounting for 73.8% of injuries ( 197/267 ) , among which motorized two - wheelers ( mtw ) were the major cause of these injuries ( 90.9% , 179/197 ) , including skids and falls , collision with other vehicles and pedestrians .
( 2 ) trauma due to fall accounted for 18.0% of injuries ( 48/267 ) , mostly involving children who fell while playing , elderly people who fell down due to systemic illness , or men who fell down under the influence of alcohol .
( 3 ) assault by a known person constituted for 6.7% of injuries ( 18/267 ) .
( 4 ) three cases of sports injury and one case of industrial injury were reported in our data.(fig .
2 , table 1 ) the test of proportion between rta and other injuries showed that there was a statistically significantly higher proportion of rta compared to other types of injuries ( p<0.001 ) .
overall results revealed that 41.6% of males ( 111/267 ) were under the influence of alcohol at the time of injury . among mtw accidents , 48.6% ( 87/179 ) of injuries were on the right side , 31.3% ( 56/179 ) were on the left side and 19.6% ( 35/179 ) were bilateral .
the test of proportion for the side of injury ( right vs left ) showed that there was a statistically significant difference in the side of injury , indicating that injury on the right side was more common compared to the left side ( p<0.05 ) .
analysis shows that 41.9% of fractures ( 112/267 ) involved the malar and maxillary bone , 33.0% ( 88/267 ) were mandibular fractures , 26.2% ( 70/267 ) were tooth ( dentoalveolar ) fractures , 8.6% ( 23/267 ) were orbital floor fractures , 7.9% ( 21/267 ) were facial bone fractures with skull bone fracture , 6.4% ( 17/267 ) were nasal bone fracture , and 6.7% ( 18/267 ) were soft tissue injuries.(fig .
3 , table 1 ) the study found that 31.1% of fractures ( 83/267 ) were treated conservatively ( 65 cases of zygomatic maxillary complex , 14 condylar fractures , and 4 nasal bone fractures ) , close reduction was performed for 27.7% of fractures ( 74/267 ) , 34.5% of fractures ( 92/267 ) were treated by open reduction , and internal fixation was performed wherever indicated .
( 1 ) the report shows that the most common cause for maxillofacial injury was rta , accounting for 73.8% of injuries ( 197/267 ) , among which motorized two - wheelers ( mtw ) were the major cause of these injuries ( 90.9% , 179/197 ) , including skids and falls , collision with other vehicles and pedestrians .
( 2 ) trauma due to fall accounted for 18.0% of injuries ( 48/267 ) , mostly involving children who fell while playing , elderly people who fell down due to systemic illness , or men who fell down under the influence of alcohol . ( 3 )
( 4 ) three cases of sports injury and one case of industrial injury were reported in our data.(fig .
2 , table 1 ) the test of proportion between rta and other injuries showed that there was a statistically significantly higher proportion of rta compared to other types of injuries ( p<0.001 ) .
overall results revealed that 41.6% of males ( 111/267 ) were under the influence of alcohol at the time of injury . among mtw accidents , 48.6% ( 87/179 ) of injuries were on the right side , 31.3% ( 56/179 ) were on the left side and 19.6% ( 35/179 ) were bilateral .
the test of proportion for the side of injury ( right vs left ) showed that there was a statistically significant difference in the side of injury , indicating that injury on the right side was more common compared to the left side ( p<0.05 ) .
analysis shows that 41.9% of fractures ( 112/267 ) involved the malar and maxillary bone , 33.0% ( 88/267 ) were mandibular fractures , 26.2% ( 70/267 ) were tooth ( dentoalveolar ) fractures , 8.6% ( 23/267 ) were orbital floor fractures , 7.9% ( 21/267 ) were facial bone fractures with skull bone fracture , 6.4% ( 17/267 ) were nasal bone fracture , and 6.7% ( 18/267 ) were soft tissue injuries.(fig .
the study found that 31.1% of fractures ( 83/267 ) were treated conservatively ( 65 cases of zygomatic maxillary complex , 14 condylar fractures , and 4 nasal bone fractures ) , close reduction was performed for 27.7% of fractures ( 74/267 ) , 34.5% of fractures ( 92/267 ) were treated by open reduction , and internal fixation was performed wherever indicated .
wound debridement was performed for 6.7% of soft tissue injuries ( 18/267).(fig . 4 , table 1 )
the maxillofacial region is the most exposed part of the body and is more vulnerable to trauma .
trauma is one of the major causes of death among people under 40 years of age1 .
major causes for maxillofacial fracture as reported worldwide are interpersonal violence , traffic accidents , falls and sports injuries3 .
rta contribute significantly to mortality and morbidity throughout the world and in large numbers in developing countries .
reports reveal that 20% to 60% of all road traffic injuries involve some form of maxillofacial injury , and 62% involve motorcycles4 .
the prevalence of maxillofacial injuries varies from 17% to 69% , and this large difference might be due to various environmental factors , socioeconomic conditions , cultural reasons , and traffic rules . in the present study ,
rta accounted for 73.8% of injuries , and mtw were the major ( 90.9% ) cause in injuries that involved skids and falls in collisions with other vehicles , including riders , pillion riders , and pedestrians .
this might be due to differences in the proportion of vehicles registered in india and three highly motorized countries ( hmc ) , the usa , china , and brazil .
the car population as a proportion of total motor vehicles is only 13% in india compared to hmcs ( 56%-80% ) . on the contrary
, the proportion of mtw is much higher ( 70% ) in india compared to hmcs .
pedestrians , bicyclists , and mtw riders are very vulnerable to injury and constitute 60% to 80% of all traffic injuries in india5 .
the number of deaths or injuries caused by mtw is about 15 to 20 times greater than for enclosed vehicles6 . in our study ,
our institution is a referral center , predominantly treating insured employees of low - income groups .
nearly ( 41.6% ) of males injured by mtw were under the influence of alcohol at the time of injury .
these injuries usually involved a skid or fall from a vehicle or collision with another vehicle or loss of control due to an unexpected encounter with pedestrians or animals
. the higher frequency of maxillofacial injuries among males compared to females is a universal finding of previous studies789 . in the present study , 74.5% ( 199/267 ) were males and 25.5% ( 68/267 ) were females , with a male to female ratio of 3:1 .
studies have reported zygomatic fractures as the most common subtype among midfacial fractures in both children and adults41011 .
the maxilla ( 22% ) , orbit ( 16% ) , and nasal ( 16% ) bones were the most frequently fractured facial bones12 . in our study , 41.9% of fractures involved the malar bone and the maxillary bone , followed by mandible fractures ( 33.0% ) , tooth ( dentoalveolar ) fractures ( 26.2% ) , orbital floor fractures ( 8.6% ) , facial bone fracture with skull bone fracture ( 7.9% ) , nasal bone fractures ( 6.4% ) , and soft tissue injuries ( 6.7% ) . in other studies ,
the incidences of facial bone fractures were 39.3% and 51.8% among children aged 6 to 10 years and 11 to 14 years , respectively , and the most commonly involved age group was 11 to 14 years1314 .
in other study reports , the incidence of facial fractures in children in india was 5.5%15 , and this could be due to the fact that young children are less often involved in occupational or violence related incidents , which are the typical causes of adult facial fractures16 .
accidental fall is the leading cause of maxillofacial injuries in children , accounting for 43% to 71.42% of injuries13151718 . among children below the age of 15 with injury due to falling while playing ,
the injury was mild , causing only soft tissue laceration or dentoalveolar or tooth fracture , rather than being a severe injury .
the literature indicates that as the age of patients increases , the patterns of fractures progressively resemble that of adult patients19 . in our study , 2.2% ( 6/267 ) of reported injuries
were in the 0 to 13 age group , and all were due to accidental fall while playing or fall from a bicycle . out of 6 patients , there were 2 dentoalveolar ( tooth ) fractures , 3 mandible fractures , and 1 zmc fracture .
this low prevalence rate might be because of mild , unnoticed injuries , or subjects may have received treatment in dental clinics outside the study area . in adults , fall was the second most common cause of injury , accounting for 18.0% ( 48/267 ) of maxillofacial injury , of which 52.1% ( 25/48 ) involved adult males , and 12 were under the influence of alcohol at the time of injury .
assault : various reports reveal domestic violence as the cause of maxillofacial injuries among women , with a prevalence between 34% and 73% , representing a worldwide problem that crosses cultural , racial and socioeconomic lines20 . in our study , 3.0% ( 8/267 ) of females and 3.7% ( 10/267 ) of males between 20 to 50 years of age had reported an assault injury by known persons .
likewise , the proportion of sports injuries was much lower in the present study , at 1.5% ( 4/267 ) , and the malefemale ratio was 3:1 .
patten of injury : the peak incidence ( 47% ) of mid - face fracture was in the age group of 21 to 30 years7 .
the most common fracture was zmc fracture , ranging from 36% to 62.5%47 . in our report
, 41.9% of fractures ( 112/267 ) involved the malar bone and maxillary bone , 33.0% ( 88/267 ) were mandible fractures , 26.2% ( 70/267 ) were tooth ( dentoalveolar ) fractures , 8.6% ( 23/267 ) were orbital floor fractures , 7.9% ( 21/267 ) were facial bone fracture with skull bone fracture , 6.4% ( 17/267 ) were nasal bone fractures , which included 2 cases of isolated nasal bone fracture , and others were associated with lefort ii and iii fractures .
reported skull bone fractures ( which were referred to our department but not requiring neurosurgical intervention ) included depressed frontal bone fractures of the outer table , temporal bone fractures , and sphenoid bone fractures .
in addition , 6.7% ( 18/267 ) of soft tissue injuries were treated by wound debridement . in the present retrospective study , an interesting point to note
was that 61.3% of malar and maxillary bone fractures were on the right side of the face .
a few patients were asked about the history of their injury , and they reported that they were right handed and had applied the right - hand brakes at the time of the accident , indicating that the front wheel possibly caused the skid . in future studies , the type of vehicle ( mtw ) and the mechanism for the side of injury should be further evaluated .
management of maxillofacial injuries is a real challenge for oral and maxillofacial surgeons , and demands both skill and expertise .
open reduction and internal fixation ( orif ) were the major types of management performed for patients.(fig .
5 ) most zmc ( s02.6 ) fractures were treated conservatively , when fractures were nondisplaced and without any functional or esthetic or neurological deficits .
dento alveolar fractures , condyle fractures without displacement or dislocation or occlusal derangement were treated by close reduction and indirect fixation by intermaxillary fixation .
zmc fractures and zygomatic arch fractures not involving occlusion were elevated by the gillies temporal approach if fractures were stable after elevation , and no direct fixation was done .
all panfacial fractures , multiple fractures with occlusal derangement , and displaced fractures that were not reduced by close reduction and unstable zmc fracture after elevation were treated by open reduction and direct fixation by miniplate osteosynthesis.(fig .
6 , 7 ) a study conducted by singh et al.21 reported that 3.88% of injured patients were intoxicated with alcohol at the time of their accidents and all were male .
agnihotri et al.22 reported that the rate of rta was increased on weekends due to an increase in the number of drivers who were under the influence of alcohol . in our study , 41.6% ( 111/267 ) of males
when approaching a cross road , in order to turn to the right hand side , the driver needs to change gear , brake , indicate , scan for oncoming traffic , make a decision on when it is safe to turn , and steer and turn the vehicle in a coordinated sequence .
prabhu et al.23 reported that even as alcohol consumption is decreasing in some developed countries , it is on the rise in developing nations , particularly among those aged 21 to 35 years .
the monthly incidence of maxillofacial fractures was fairly constant along with seasonal variations , as reported in several previous studies142425 .
to november is the rainy season , and there is an increased incidence of accidental falls and rta . in the present study ,
our reports revealed that the main cause of maxillofacial injury was rta , and males aged 20 to 40 years more often sustained maxillofacial injury .
fractures of the malar bone and maxilla were the major prevalent fractures in the maxillofacial region , mtw were the major cause of injury , and the influence of alcohol was also one of the important factors responsible for injuries . although the majority of malar and maxillary fractures were treated conservatively , orif was performed wherever indicated .
 objectivesthis retrospective study aims to evaluate the prevalence of maxillofacial trauma in a developing country , along with its pattern , etiology and management . 
 data for the present study were collected from the department of dentistry , esic medical college and post graduate institute of medical sciences and research , chennai in india.materials and methodsthe medical records of patients treated for maxillofacial injuries between may 2014 and november 2015 were retrospectively retrieved and analyzed for prevalence , pattern , etiology , and management of maxillofacial trauma . 
 spss software version 16.0 was used for the data analysis.resultsmaxillofacial fractures accounts for 93.3% of total injuries . 
 the mean and standard deviation for the age of the patients were 35.011.8 years and with a minimum age of 5 years and maximum age of 75 years . 
 adults from 20 to 40 years age groups were more commonly involved , with a male to female ratio of 3:1 . 
 there was a statistically significantly higher proportion of males more commonly involved in accident and injuries ( p < 0.001).conclusionthe most common etiology of maxillofacial injury was road traffic accidents ( rta ) followed by falls and assaults , the sports injuries seem to be very less . in rta , 
 motorized two - wheelers ( mtw ) were the most common cause of incidents . 
 the majority of victims of rta were young adult males between the ages of 20 to 40 years . 
 the malar bone and maxilla were the most common sites of fracture , followed by the mandible . 
 the right side of the zygomatic complex was the predominant side of mtw injury . 
 the majority of the zygomatic complex fractures were treated by conservative management . 
 open reduction and internal fixation were performed for indicated fracture patients . 
I. Introduction
II. Materials and Methods
III. Results
1. Etiology
2. Site or type of fracture
3. Management
IV. Discussion
V. Conclusion