Maxillofacial fractures represent a significant portion of trauma cases encountered in emergency departments globally, often necessitating specialized care due to their complex anatomical and functional implications.1, 2 Understanding the epidemiological patterns of these fractures is crucial for developing effective preventive strategies, optimizing resource allocation, and improving clinical outcomes.

Kerala is known for its advanced healthcare system; tertiary trauma centers play a pivotal role in managing severe and complex trauma cases.3 Despite the critical importance of understanding the local patterns of maxillofacial fractures, there has been a paucity of comprehensive studies focusing on this region over an extended period.

This study aims to bridge this gap by providing a retrospective analysis of maxillofacial fracture cases reported to a major tertiary trauma center in Kerala over the past decade. By examining a decade’s data, the study seeks to identify trends, demographic patterns, common causes, and the types of fractures prevalent in this geographical area. Such an analysis not only contributes to the existing body of knowledge but also aids in formulating region-specific preventive measures, enhancing trauma care protocols, and informing policy decisions.

Patient selection

Data gathered from the Department of Oral and Maxillofacial Surgery at the Government Dental College and Hospital in Thiruvananthapuram, Kerala, served as the basis for this retrospective investigation. The study, which was conducted by the 1975 Helsinki Declaration, received ethical approval from the Institutional Ethical Committee Ref. no. ICE/28/2020/GDCT. The investigation employed the use of information of 48,708 casualty patients, collected from the hospital’s central database registry of patients who presented to the emergency room between January 2010 and December 2020, with maxillofacial fractures. Patients with clinical-radiographic diagnoses of maxillofacial bone injuries aged between 18 to 65 years, regardless of gender, met the inclusion criteria. Pregnant women, cases with polytrauma, pan facial injuries, soft tissue injury devoid of fractures, and cases with incomplete data in the registry were excluded.

Parameters assessed

The variables documented for each patient included gender, the cause of the injury, the date of the incident, the type and location of the facial fracture, and any related traumatic brain damage or cervical spinal injury. The etiology was further subdivided into road traffic accidents (RTA), industrial accidents, sports injuries, assaults, falls, pathologic, iatrogenic, and others. The classification of facial fractures included mandibular fractures, Lefort fractures, Naso-Orbito-Ethmoidal (NOE), Zygomatico-Maxillary-Complex (ZMC), and mid-palatal fractures.

Statistical Analysis

We used the Statistical Package for the Social Sciences (SPSS version 21.0, IBM, Chicago, IL) to analyze all the data that were entered into Microsoft Excel. Since the variables were categorical, the data were shown as percentages. To identify relationships between categorical variables, the Chi-square test was used; a p-value of ≤0.05 was deemed statistically significant.

Demography

There were significant differences between the frequency of male and female patients with maxillofacial fractures from 2010 to 2020. Graph 1indicate that throughout this period, the number of males with fractures consistently exceeds the number of females every year. There are large variations in the male population, with peaks over 4500 in 2012, 2013, 2017, and 2019, and notable declines in 2015 and 2020. On the other hand, the number of fractures in the female population has been reasonably constant over time, averaging far less than the male population. It peaked at 500 and has remained constant over time. The years 2010 and 2020 reported the highest number of females with maxillofacial fractures, while 2014 and 2016 saw the lowest number.

Aetiology

Road Traffic Accident

The number of RTAs, or road traffic accidents, varied greatly from 2010 to 2020. The substantial changes are depicted in Graph 2, which shows noteworthy peaks of cases in 2011 and 2019 as well as considerable falls in 2015 and 2020. Beginning at about 3000 cases in 2010, the number increased to roughly 4000 by 2011 and remained constant in 2012. A persistent decrease ensues, culminating in the lowest levels of around 2500 cases by 2015. Following that, the number of incidents rises, reaching a peak by the end of 2019 with almost 4500 cases; the highest recorded over 10 years. But in 2020, there is a dramatic fall in the number of instances, with accidents reaching a record low of about 1500, the lowest in the previous ten years. The data demonstrates variability with an overall upward trend until 2019 before a sharp decline in 2020.

Influence of Alcohol

Graph 3 illustrates the different patterns in the effect of alcohol on cases from 2010 to 2020. The breath analyzer results began at 198.00 µg/100 ml in 2010 and decreased progressively over time, with sporadic fluctuations. 2020 saw a sharp decline in the numbers, reaching 37.42 µg/100, which was much lower than in prior years. All things considered, the data points to a general pattern of declining alcohol prevalence in cases throughout the course of the decade, with a notable reduction seen in 2020.

Assault

The number of assault-related fractures of the face that were recorded between 2010 and 2020 fluctuated, peaking at 832 cases in 2012 and falling to 286 by 2015 (Graph 4). According to the data, there was a spike in assaults from 2010 to 2012, followed by a general downward trend. There were notable declines in 2013, 2015, and 2015. The number of attacks did, however, rise in 2016 (345) and 2017 (502), before falling once more in 2020 (293 assaults). Over the course of the decade, there was a notable decrease in attacks.

Sports Injury

Sports accidents resulting in facial fractures showed notable variations between 2010 and 2020. (Graph 5) After peaking at 87 injuries in 2010, the number fell to 66 in 2011, then jumped to 97 in 2012, and then increased further to 210 cases in 2013. The upward trend continued, peaking at 374 injuries in 2014. This was followed by a sharp fall to 248 cases in 2015, and during the next several years till 2018, there were a few minor rises and falls. With 236 injuries in 2019 and reducing to 160 in 2020, a downward trend continued. Sports injuries increased significantly overall in the first half of the decade, peaking in 2014, and then generally declined towards the end of the period.

Self-Fall

The number of self-falls resulting in facial fractures varied greatly between 2010 and 2020; from 262 events in 2010 to 179 cases in 2020. Rise and fall in the number of cases were observed between 2010 and 2020. Self-falls mainly peaked in 2013 and then generally decreased as the decade came to an end (Graph 6).

Industrial Accidents

Graph 7 illustrates the fluctuations in the number of industrial accidents from 2010 to 2020. According to the records, there were 15 accidents in 2010, three in 2011, 17 instances in 2012, and fourteen cases in 2013. There were seven accidents in both 2014 and 2015, followed by three in 2016, seven in 2017, two in 2018, and nine in 2019. There were no documented industrial incidents in 2020. Generally, during the course of the decade, there were variations in the number of industrial accidents, with occasional years reporting no incidents.

Pathologic

From 2010 to 2020, pathologic incidents causing facial fractures were sporadic but generally low in frequency (Graph 8). In 2010, 2011, and 2017 no cases were reported. There were three cases in 2012, 2013, and 2015, while just two were documented in 2014 and 2016. The number of events rose to three in 2018 and then fell to one in 2019 and 2020. Overall, pathologic incidences had a shifting pattern throughout the decade, reaching a high in 2013 and showing decreasing numbers in subsequent years.

Iatrogenic

From 2010 to 2020, iatrogenic incidents varied annually, with no incidents reported in 2010, 2013, 2014, 2015, and 2020. One incident occurred in 2011, two in 2012 and 2016, and three in 2019, showing fluctuation in reported cases over the decade (Graph 9).

Accidental Hit & Other

From 2010 to 2020, cases caused by "Accidental hit" incidents varied significantly, ranging from 21 in 2010 to a peak of 202 in 2017, with notable fluctuations in between such as 134 in 2014 and 119 in 2020 (Graph 10). In contrast, incidents categorized under "Others" were generally low, with a peak of 31 in 2016 and minimal occurrences in other years, reflecting a stable but infrequent pattern throughout the decade (Graph 11).

Road traffic accidents account for the majority at 72.85%, reflecting a significant portion of the reported incidents. The assault follows at 11.16%, indicating a notable but smaller fraction compared to road accidents. Self-falls contribute 7.89% of the incidents, while sports injuries make up 4.62%. The remaining categories, including iatrogenic incidents at 0.02%, pathological fractures at 0.04%, others at 0.08%, accidental hits at 2.48%, and industrial accidents at 0.16%, collectively represent smaller proportions of the total reported incidents. (Graph 12). This distribution underscores road traffic accidents as the most prevalent cause, with the other categories contributing to varying degrees across the reported incidents.

Type of Injury

Tooth fractures

Ellis Class 1 fractures were the next most frequent, ranging from 443 to 890 incidents annually. Ellis Class 2 fractures varied from 476 to 630 incidents per year, while Ellis Class 3 fractures ranged between 469 and 613 incidents annually. (Graph 13). Crown en mass fractures were less frequent, with numbers ranging from 134 to 242 per year. Avulsed tooth incidents were consistent, ranging from 151 to 239 cases annually (Graph 14). Ellis Class 1 fractures account for the majority at 34%, reflecting a significant portion of the reported incidents over 10 years. Ellis Class 2 and 3 fractures follow at 28% and 27% (Graph 15).

Facial Fractures

Mandibular fractures showed variation between 370 and 490 incidents per year, with Leforte fractures ranging from 365 to 477 cases annually. Nasoorbitoethmoid fractures varied between 121 and 150 cases annually, while condyle fractures ranged from 210 to 306 per year. Blowout fractures were reported between 253 and 284 incidents annually, and ZMC fractures ranged from 178 to 216 cases per year. Midpalatal split fractures were recorded between 155 and 178 cases annually (Graph 16). Mandible fractures account for the majority at 25%, reflecting a significant portion of the reported incidents over 10 years. Leforte and ZMC fractures follow at 23% and 21% respectively. Blowout fractures account for 13% of all the cases and the incidence of mid palatal split (10%) and naso-ethmoidal fractures (8%) is the least among all the facial fractures of the years (Graph 17).

Associated Injury

From 2010 to 2020, the data shows the annual occurrences of head injuries and cervical spine injuries associated with maxillofacial injury. Head injuries consistently had higher incidences each year, ranging from 880 cases in 2015 to a peak of 2088 cases in 2010, with fluctuations throughout the decade. In contrast, cervical spine injuries were relatively rare, varying from three cases in 2020 to a peak of 66 cases in 2018, generally maintaining low numbers compared to head injuries across all years (Graph 18).

Tables and Graphs

Graph 1: Distribution of cases based on Gender

Graph 2: Distribution of cases based on road traffic accidents

Graph 3: Distribution of cases based on the influence of alcohol

Graph 4: Distribution of cases based on assault

Graph 5: Distribution of cases based on sports injuries

Graph 6: Distribution of cases caused by Self-Fall

Graph 7: Distribution of cases caused by industrial accidents

Graph 8: Distribution of cases caused by pathological causes

Graph 9: Distribution of cases based on iatrogenic causes

Graph 10: Distribution of cases caused by accidental hit

Graph 11: Distribution of cases caused by Other causes

Graph 12: Summary of Incidence Rates of cases based on etiology

Graph 13: Distribution of cases based on Ellis class of fractures

Graph 14: Distribution of cases based on Crown en mass fracture and avulsed tooth

Graph 15: Summary of Incidence Rates of cases with tooth fractures

Graph 16: Distribution of cases based on the type of facial bone fracture

Graph 17: Summary of Incidence Rates for Different Facial Fractures (2010-2020)

Graph 18: Distribution of cases based on other associated injury.

According to this study, the frequency of facial fractures in males was found to be greater, resulting from reckless driving, working outside, and alcoholism. Due to the current socioeconomic structure in the area, males participate in outdoor activities and drive more frequently than women. The frequency and etiology of maxillofacial injuries have changed throughout time. Road traffic accidents (RTAs) continue to be the most frequent cause in developing nations, whereas interpersonal violence remains the most prevalent cause in affluent countries. Research by Adekeye, Ravidran, Tan, and Lim similarly concludes that RTAs account for most maxillofacial fractures in developing nations.4-6 Our research also shows that RTAs were the main etiology for maxillofacial fractures, in contrast to self-fall, which Siber describes as a frequent cause of face fracture.7 Notwithstanding the stringent government rules, inadequate road infrastructure, carelessness about traffic, and neglect of road safety regulations are reasons for the rise in RTAs in Kerala.

There was a noteworthy decline in the incidence of RTA in the year 2020. Transportation options were restricted during COVID-19 shutdown phases 1 and 2, which resulted in workplace closures and the implementation of a "Work from Home" approach. Phase 3 permitted travel for emergencies and necessities, but by December 2020, the effects on accident statistics and traffic patterns had become less apparent. In Phase 4, private vehicle travel gradually eased, and time-controlled commercial stores developed to draw in daytime customers. Despite a slight rise in accidents, the State Crime Records Bureau recorded a 14% decrease in road deaths in the first three months of 2020. In the first quarter of 2020, the Safe Kerala Project made great strides toward meeting its goals for road safety. Limiting automobile traffic and encouraging walk-to-work journeys helped slow the rising trend in accidents. Due to their lack of enclosed protection, rapid speed over short distances, and reduced stability, motorized two-wheeler vehicles are particularly vulnerable to traffic accidents. In addition, bicycle accidents are frequent in urban areas.

Alcoholism is a major cause of disease and death worldwide. The Indian state of Kerala has higher alcohol consumption rates than the country as a whole. Roughly 3 million adult men in Thiruvananthapuram, Kerala, had drank alcohol in the last 12 months, accounting for 28.87% of the total population. Of the drinking male population in Kerala, 8.8% drink practically daily, 26.5% drink for about one to four days a week, and 10.5% reported binge drinking during the weekends. An estimated 14% of men are heavy alcohol users, accounting for 1.5 million cases of hazardous drinking. The state has over 400,000 males who suffer from severe addiction, with alcohol dependency at 2.6% and abuse at 1.2%.8 There is ample evidence linking alcohol use to maxillofacial trauma. Alcohol affects brain receptor function and neurotransmission, which reduces fear and anxiety about the social, legal, or physical repercussions of one’s conduct. Leading to more serious fractures. Furthermore, alcohol inhibits and impairs cognitive function and motor reflexes, increases aggressiveness, and elicits excessive emotional reactions.8, 9

Maxillofacial fractures resulting from assault entail the person being abused physically, emotionally, and psychologically. The most common target for physical violence is the face due to its conspicuous and accessible location; however, it has also been proposed that the aggressor’s primary intention while causing facial injuries is to undermine the victim’s self-esteem.10 Domestic abuse, which mostly occurs at home, is especially common among women in their 20s and 30s and accounts for around half of the violence-related injuries that oral and maxillofacial surgeons examine. Fractures and face injuries are typical signs of domestic violence, and women are more likely to know their attacker and experience assaults at home. 11

Facial injuries are common in sports, with severity varying greatly. Understanding the diagnosis and treatment of these injuries is crucial for athletes’ health care. Common injuries include player-to-player contact, falls, and direct hits with equipment. Soft-tissue injuries, such as lacerations, abrasions, and contusions, can also occur. Approximately 11% to 40% of sports injuries involve the face, with 8% of facial soft tissue injuries being sports-related. In pediatrics, craniofacial injuries represent up to 20% of all sports-related injuries.12

The hospital’s proximity to a seaside location, where many people work and climb coconut trees, may contribute to a high incidence of facial injuries due to falls. This could also be linked to conditions like seizures and unintentional falls. The advancements in machinery, electrical power, and chemicalization have increased the risk of human life in various sectors, emphasizing the importance of occupational safety. Pathologic fractures affect skeletal biomechanics and arise in regions of compromised bone due to malignant, benign, metastasizing, or metabolic disorders. They represent 1% to 2% of fractures and are extremely uncommon. Tumors, infections, and jaw osteonecrosis are among the common causes. Improvements in the diagnosis and treatment of metastatic diseases are resulting in more frequent identification of these fractures.

Medical treatments such as orthodontic and reconstructive operations, dental procedures, and the use of medical gadgets can all result in iatrogenic facial fractures. Head and neck ailments, anesthesia-related events, and medical gadgets can all result in fractures. They emphasize how critical it is to perform maxillofacial treatments with exacting surgical skills and attentive management. Injury patterns differ depending on the patient group; falls, trips, and slips are more prevalent in the elderly and youngsters, whereas the main causes of injuries in those between the ages of 15 and 50 are motor vehicle crashes and violence. These injuries may be related to craniofacial fractures or they may be limited to soft tissues.12

Traumatic dental injuries can vary widely in severity, from simple cracks affecting the pulp and crown to more complicated fractures involving the supporting periodontium. Emergency care is necessary for these injuries as they are frequently unexpected and situational. They can result in pain, and discomfort and can often restrain the individual from smiling or laughing.13 Facial bone fractures are less prevalent in pediatric patients, with soft tissue and dento-alveolar injuries accounting for most maxillofacial trauma cases.14 Fractures, luxations, and avulsions are examples of tooth damage that are typically reduced. However, avulsions are dangerous and can have erratic prognoses which include pulp infection, superficial resorption, inflammatory resorption, and replacement resorption.15

We found that the most prevalent fracture in this study was a mandibular fracture, which was followed by zygomaticomaxillary complex and Lefort fractures. The mandible is a prominent bone in the maxillofacial region, with fractures affecting single or multiple sites. 36%–59% of all maxillofacial fractures are mandibular fractures, making them the most prevalent kind.16 Most fractures occur in the condyle, followed by the angle of the mandible.17 Any blow or force applied on the chin is directed towards the condyle, increasing the risk of fracture.18 Over 50% of facial bone fractures are midface fractures, with LeFort fractures accounting for 23% of documented instances. The midface area serves as a cushion to protect the brain and spinal cord by absorbing any stress delivered to the skull.19 Offering both vertical and horizontal support to the face framework, the zygomaticomaxillary complex (ZMC) is an intricate and crucial facial structure. Due to its conspicuous location, it is more likely to fracture either by itself or in conjunction with other midface components such as the orbital region, nasoethmoidal, and maxilla.20 If left untreated, blow-out orbital fractures can result in both functional and cosmetic concerns. These complex facial fractures can cause progressive and long-term complications, and they are more prevalent in high-speed, high-force collisions. Nasoorbitoethmoidal fractures are uncommon and frequently occur in conjunction with other injuries, including cribriform plate fractures, CNS injuries, and fractures of the frontal, orbital, and middle part of the face.21

As maxillofacial bones are close to the cranium, they may cause simultaneous cranial injuries, with forces transmitted through the face potentially impacting the neurocranium, causing more severe brain injuries. Surgeons must be aware of the potential consequences of head injuries related to facial trauma and be equipped to treat them appropriately.22 Cervical spine injuries (CSI) are often linked to facial trauma. Research has shown that pressures influencing cervical structures, whether directly or indirectly affecting both soft tissues and bone of the face can result in CSI. When it comes to managing facial injuries, the existence of CSI can have a big impact on judgments about when and whether surgical procedures are necessary.23

The investigation concluded that RTAs, primarily under the influence of alcohol, constituted a prevalent etiological cause for maxillofacial fractures in the aforementioned geographic area, with a predominance of mandibular fractures. Considering the prevalence of males in maxillofacial trauma cases, targeted interventions aimed at reducing risk factors like rash driving and alcoholism are needed. Educating the public about safe driving practices and the dangers of alcohol consumption could potentially reduce such injuries. The results advocate for enhanced road safety protocols in Kerala, encompassing stringent implementation of traffic regulations, improved road infrastructure, and heightened public education regarding road safety to mitigate the prevalence and gravity of maxillofacial injuries. In order to ensure that trauma centres are appropriately prepared to manage peak periods of trauma patients, it might be helpful to understand the seasonal and temporal fluctuations in the occurrence of maxillofacial fractures.

Conflicts of interest

The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

Funding

The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.                     

Authors’ contributions

All authors contributed equally to the manuscript and read and approved the final version of the manuscript.

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