key: cord-0277293-djpu2xjz authors: Aleksanyan, L.; Poghosyan, A.; Misakyan, M.; Minasyan, A.; Bablumyan, A.; Tadevosyan, A.; Muradyan, A. title: EPIDEMIOLOGY OF MAXILLOFACIAL INJURIES IN "HERATSI" numero1 UNIVERSITY HOSPITAL IN YEREVAN, ARMENIA: A RETROSPECTIVE STUDY date: 2021-06-02 journal: nan DOI: 10.1101/2021.06.02.21258208 sha: 81720100e7348fd23ec440c12f2e5c1468f40f02 doc_id: 277293 cord_uid: djpu2xjz Objective: The aim of this study was to perform a retrospective analysis of the prevalence, etiologies, and types of maxillofacial injuries (MFI) and sites of maxillofacial fractures (MFF) and their management in the Department of ENT and Maxillofacial Surgery of "Heratsi" No. 1 University Hospital in Yerevan, Armenia. Material and methods: A retrospective cross-sectional study was conducted. Data including age, sex, date of referral, mode of injury, etiology, radiology records and treatment methods were extracted. Study outcomes were measured using percentages, means, standard deviations and tests of proportions. P <.05 was considered significant. Results: A total of 204 patients had a mean age of 36.26 years (156 males and 48 females), and a total of 259 MFIs were recorded between 2017 and 2020. Interpersonal violence (IV) was found to be the most common etiology of MFFs in this study (42.1%), followed by road traffic accidents (RTAs) (27.9%) and falls (18.6%). The nasal bone was the most common injury site (47.5%), followed by the mandible (31.4%) and zygomatic complex (11.7%). The most common fracture site was the mandibular angle (37.9%), followed by the symphysis/parasymphysis (28.1%) and body (12.6%). The majority of MFFs were treated by open reduction and internal fixation. Conclusion: Interpersonal violence, followed by RTAs and falls, was the most common cause of MFIs. The nasal bone was the most common injury site, followed by the mandible and zygomatic complex. Social education with the objective of reducing aggression and interpersonal conflict should be improved, and appropriate RTA prevention strategies should be strengthened and implemented. Traumatic injuries continue to be important causes of morbidity and mortality in both developed and developing regions. [1] [2] [3] [4] The epidemiology of facial injuries varies among different countries and geographic zones. Population concentration, lifestyle, cultural background, and socioeconomic status can affect the prevalence of maxillofacial injuries (MFIs). [4] [5] [6] [7] In addition to population and societal changes, the incidence rates and patterns of maxillofacial fractures (MFFs) may also vary among time periods due to legislative changes such as the introduction of compulsory safety belt legislation, helmet use, and speed limit enforcement. [6] [7] [8] [9] [10] Traumatic injuries represent a significant and growing disease burden in the developing world and are now one of the leading causes of death in economically active adults in many low-and middleincome countries. [4, 9, 11] According to the World Health Organization (WHO), middle-income countries have higher injury and death rates than low-and high-income countries. [3, 12] In addition an increasing total proportion of injuries in developing countries, among the total number of injuries to the maxillofacial region, the percentage of combined injuries is increasing, which indicates serious suffering among patient and prolonged hospitalization and rehabilitation. [2, [13] [14] [15] Maxillofacial fractures can be considered consequential injuries, as they may result in mortality, severe morbidity, facial disfigurement, and functional limitations. [2] Knowledge about the epidemiology of MFF can help practitioners make appropriate clinical decisions and guide professionals and policy makers concerned with developing suitable injury prevention strategies. The aim of this study was to perform a retrospective analysis of the prevalence, etiologies, and types of maxillofacial injuries and sites of maxillofacial fractures and their All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Patients and the public were not involved in any way A retrospective cross-sectional study was conducted. The medical records of hospitalized patients with MFIs admitted to the Department of ENT and Maxillofacial Surgery at <> No. 1 University Hospital in Yerevan, Armenia, between January 2017 and December 2020 were retrieved and analyzed to obtain prevalence, etiology, injury pattern and treatment modality data. The exclusion criteria were as follows: 1) outpatients offered immediate treatment without hospitalization; 2) patients with only soft tissue injuries who were treated in the emergency room without hospitalization; or 3) military patients wounded during the war from October-November 2020. After excluding such patients, the records of 204 patients aged between 12 and 90 years were retrospectively analyzed. The sample size calculation n = Z 2 pq/ Δ 2 was performed for a one group proportion, where p=0.5, Δ =0.07, n=196. Data on age, sex, date of referral, mode of injury, etiology, radiographic findings with radiology records and treatment methods were extracted. Injury etiology was classified into four All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint main categories: (1) RTAs involving automobiles, motorcycles and bicycles, including drivers, pillion riders, passengers, and pedestrians; (2) falls from heights, household falls, and falls due to systemic illness such as epilepsy or while playing; (3) assaults or interpersonal violence; and (4) sport-related and other injuries. Ethical considerations were taken into account throughout the study, and the patients' names and medical information were kept completely confidential. The subjects' medical history was used solely for the purposes of the current study. Statistical analysis was performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Study outcomes were measured using percentages, means, standard deviations and tests of proportions. The prevalence rates of injuries in particular age, sex, etiology, and fracture type All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint groups were analyzed. Non parametric statistic test (Pearson' χ 2) was used describing nominal data. Only for description of patients age mean and SD was applied. Patient-and injury-related variables, including age, sex, anatomic location of the fracture, and etiology, were analyzed with χ 2 tests or tables larger than 2x2, a post hoc test with Bonferroni correction was used. As presented in Figure 2 , males in the 21-30 years age group had the highest prevalence (33.4%; n=68). The highest prevalence in females occurred in the age groups over 61 years (6.4%; n=13). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Le-Fort fractures were reported in seven (3.4%) cases, of which six were due to RTAs and one was due to an industrial injury. Orbital floor fractures accounted for 3.4% (7/204) of the All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. As per the World Bank's classification, Armenia is a developing country with an upper middleincome economy. The population of Armenia was 2,296,243 in 2020. Maxillofacial fractures (MFFs) not only cause serious physiological injuries but also impose serious burdens on society due to morbidity, mortality, facial disfigurement, loss of function, and financial expenditures associated with such injuries. [4, 16- 18] The incidence rates, etiologies, types, and injuries associated with MFFs vary among different countries and even different areas within the same country due to environmental, socioeconomic, cultural, and lifestyle differences among people. [4, 7, 16] The proportion of males affected by MFFs in this study was higher than that of females, at 3.25:1, which is in agreement with findings reported in most other studies. [1, 2, 4, 9, [19] [20] [21] [22] IV was found to be the most common etiology of MFF in this study (42.1%, n=190), followed by RTAs (27.9%, n=190) and falls (18.6%, n=190). Most studies on the etiology of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint maxillofacial trauma in developing countries indicate that RTAs are the most frequent cause of MFIs. [3, 5, 6, 10, 17] In contrast, the most frequent cause of MFFs in developed countries is IV or assault. [1, 6, 10, 15, [23] [24] [25] Sbordone et al., [26] in their multicentric retrospective study in southern Italy in 2018, showed that the most frequent cause of facial injuries was assault (30.4%), followed by RTAs [24] in their study on the epidemiology of mandibular fractures in the United States. They found that the mechanism of injury differed by sex, with men most frequently sustaining mandibular fractures from assaults (49.1%), followed by motor vehicle accidents (MVAs; 25.4%) and falls (12.8%); women most frequently sustained mandibular fracture from MVAs (53.7%), followed by assaults (14.5%) and falls (23.7%). Falls were a significantly more common etiology in patients who were 65 years or older. Therefore, the MFF epidemiology data obtained in the present study are comparable with data from Europe and the United States. The 21-40 years age group had the highest MFI incidence rate in the present study. These data are in accordance with data obtained by many other researchers. [6, 7, 9, 15, 17, 19, 23, 27] The main etiological cause of injuries in the 21-30 years age group was IV, followed by RTAs. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint The high rate in this age group may be due to participation in outdoor activities or psychosocial problems that may provoke risk-taking behaviors, thus making this population more prone to injuries. [28] In this study, patient age was found to be associated with the fracture site. It was demonstrated that patients aged 21-30 years were likely to have sustained nasal bone fractures (40.5%) and mandible fractures (40.5%) in equal proportions. The lowest MFI rate was observed in the elderly age group (>60), with the main etiology of injuries in this group being falls (65%, 13/20). The most common MFF site and type following trauma varied among studies. The results from most studies showed that the mandible was most commonly affected area. [6, 7, 9, 15, 17, 20, 21, 26, 27] However, in this study, the nasal bones were found to be the most common injury site (47.5%, n=204), followed by the mandible (31.4%, n=204) and zygomatic complex (11.7%, n=204). Comparable data presented by Rezaei et al. [27] in a retrospective study of epidemiology of maxillofacial trauma in a university hospital in Kermanshah, Iran, observed nasal fracture to be the most frequent type of trauma (45.5%), followed by mandibular (29%) and zygomatic (24.9) fractures. The dominance of nasal bone injuries compared to other sites was also noted by Agnihotri et al. [29] who found that the most common bone to be affected was the nasal bone (23.7%), followed by the mandible (22.7%) and zygoma (19.3%). However, the percentage of nasal fractures was two times less than that in the present study, at 23.7% in their study and 47.5% in the current study. The zygoma was the most fractured anatomical site in both males and females in the study by Arangio et al. [20] , accounting for 32% of all injuries, followed by isolated fracture of the orbital floor, at 11%. Singaram et al. [10] conducted a retrospective study and showed that 41.9% of fractures were zygoma and maxillary bone fractures, 33.0% were All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The most common fracture site was the mandibular angle (37.9%, n=103), followed by the symphysis/parasymphysis (28.1%, n=103) and body (12.6%, n=103). A similar finding on mandible fracture loci distribution was presented by Morris et al., [19] with the angle accounting for 27%, symphysis accounting for 21.3%, and condyle and subcondyle accounting for 18.4%. Additionally, Ferrer et al. [23] found the most common fracture site to be the mandibular angle (35%), followed by the parasymphysis (30%). Afrooz et al. [24] , Kaura et al. [9] and Abhinav et al. [15] noted that the most common site of mandible fracture was the parasymphysis. The results of the EURMAT collaboration by Boffano et al. [1] revealed condylar fracture as the most commonly observed type of mandibular fracture, accounting for 34%, followed by body fractures, angle fractures and fractures of the symphyseal region. Combined mandible fractures accounted for 59.4% (38/64), and the most frequent association in the present study was the angle and the parasymphysis. MFFs can be treated with either closed reduction (conservative) or ORIF (surgical) methods or a combined approach. The decision regarding treatment depends on a variety of factors, such as the nature of the injury, the presence of associated injuries and comorbidities, the skill of the surgeon, etc. In the present study, close reduction was performed in all patients with nasal bone fractures and ten patients with minimally displaced zygomatico-maxillary and zygomatic arch fractures. A total of 42.6% of the fractures were treated by ORIF. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint Interpersonal violence, followed by RTAs and falls, was the most common cause of MFIs. The nasal bone was the most common injury site, followed by the mandible and zygomatic complex. Social education with the objective of reducing aggression and interpersonal conflict should be improved, and appropriate RTA prevention strategies should be strengthened and implemented. 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The copyright holder for this preprint this version posted Retrospective study of facial fractures Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study Cost analysis of facial injury treatment in two university hospitals in Malaysia: a prospective study Pattern of maxillofacial and associated injuries in road traffic accidents The relationship between head injury and facial trauma: a case-control study The patterns and etiology of maxillofacial trauma in South India Global trends in maxillofacial fractures Causes and incidence of maxillofacial injuries in India: 12-year retrospective study of 4437 patients in a tertiary hospital in Gujarat No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted Complications in facial trauma Mandibular fractures: an analysis of the epidemiology and patterns of injury in 4,143 fractures Maxillofacial fractures in the province of Latina Maxillofacial trauma in the gulf countries: a systematic review Patterns of maxillofacial injuries in the Middle East and North Africa: a systematic review Epidemiological study of the socioeconomic impact of mandible fractures in a Spanish tertiary hospital: review of the literature The epidemiology of mandibular fractures in the united states, part 1: a review of 13,142 cases from the US National trauma data bank Etiology and injury patterns of maxillofacial fractures from the years No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted The influence of socioeconomic factors on the epidemiology of maxillofacial fractures in Southern Italy Epidemiology of maxillofacial trauma in a university hospital of Kermanshah, Iran Multiple risk behavior and injury: an international analysis of young people Incidence and pattern of maxillofacial trauma due to road traffic accidents: a prospective study None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to declare. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The data that support the findings of this study are available from the corresponding author, upon request.All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.06.02.21258208 doi: medRxiv preprint