This study evidences a high incidence of maxillofacial fractures in the 20–29 age group, which is in accordance with the results reported by other authors [2, 4, 9–20]. This finding can be due to the fact that during this life decade, individuals are more socially, professionally and physically active, being more exposed to trauma [2–4]. Young people are more extroverted and participate in social events more often [12]. In these circumstances, consumption of alcohol or recreational drugs predisposes them to interpersonal conflicts which can lead to physical aggression [12, 21, 22]. For the same reasons, the patients belonging to this life decade are predisposed to road traffic accidents due to their lack of experience, breaking of traffic rules or high-speed driving [15–23]. Contrary to our findings, in other studies the incidence of maxillofacial fractures is predominant in the 30–39 age group [24–26]. This can be attributed to global population aging [17].
Maxillofacial fractures predominate among men, both in this study and in the literature [9–23]. Behaviorally, men are more predisposed to engage in interpersonal conflicts than women, therefore the risk to suffer a fracture caused by aggression being higher [27]. With respect to daily activities, men are more frequently involved in physical work, for example in construction works, being more predisposed to work accidents [23–27]. Extreme sports or contact sports are also predominantly practiced by men, who are at a higher risk for maxillofacial fractures caused by sports injuries [2–6]. However, in developed countries, where women are involved in society as much as men, the male/female ratio tends to decrease [28–30].
A higher incidence of maxillofacial fractures was found in urban areas in our study, which is in accordance with the results of other publications [27, 31–33]. The high density of the population in the urban environment, the great discrepancies between social classes, the easy access to alcohol or narcotic substances are factors that contribute to increasing the risk of interpersonal conflicts [27, 31–33]. Also, the city infrastructure based on highways allowing high-speed circulation of vehicles, concomitantly with the multiplying number of vehicles, leads to an increase in the risk of road traffic accidents [27–33]. Contrary to our findings, other studies indicate a higher frequency of maxillofacial fractures in rural areas [34]. These discrepancies can be explained by the differences between the regions served by the institutions in which those studies were carried out [34]. In our study, an increased incidence of interpersonal violence in both environments was found. This result is uncommom and rarely found in the existing literature [2, 6]. Also our institution where the study took place serves many counties composed of both urban and rural regions. This fact can also explain our result.
In our study we found that most of the affected patients had a low level of education. This result is also reported by other authors [17, 35, 36] A lower education level predisposes to unemployment, low social status, material deficiencies and implicitly, limited access to healthcare services [17]. All these factors can lead to frustration and depression which, supported by alcohol or drug consumption, can lead to conflicts and interpersonal violence [22, 23, 35, 36]. These findings are upheld by other authors who certify the small number of traumas secondary to aggression in a population with a high education level [23, 36]. Also, in the context of the absence of an intellectual qualification, people are forced to earn their living by practicing unqualified physical work [17]. The risk to suffer a maxillofacial fracture through a work accident is higher in this context compared to the intellectual work environment [17]. According to our and other authors’ results, the increase in the education level of a population is a significant method for the prevention of maxillofacial fractures [22, 23, 36]. Although the highest incidence of fractures caused by interpersonal violence was found among patients without education, our study evidences the predominance of interpersonal violence as a main etiological factor in the other education level categories as well. This fact is rarely found in the literature and it must be considered an alarm signal in public health [22–27].
The most frequent mechanism of maxillofacial fractures was interpersonal violence, a result also found in studies conducted in other geographical areas such as Germany [37], Brazil [6, 33], USA [24, 31, 39], Italy [26, 38], Australia [7], Norway [2, 29] or Sweden [40]. The incidence of interpersonal violence has increased over the past decade in developed countries [29–39]. Recent European studies confirm a shift of the main etiological factor of maxillofacial fractures from road traffic accidents or sports injuries to interpersonal violence [2, 26, 40]. The cultural, social and educational mosaic in the cities of developed countries is an environment that constantly predisposes to interpersonal conflicts and implicitly, to maxillofacial fractures [26–39]. The interrelation between interpersonal violence and alcohol found in developed countries should not be overlooked either [37–40]. For example, in Arab countries where alcohol consumption is restricted or even forbidden by law, interpersonal violence has a low incidence [41, 42].
In contrast to our findings, in studies conducted in regions such as Nigeria [43], Uganda [20], India [17, 19, 27], Egypt [1], Saudi Arabia [41, 42], China [19], South Korea [15, 30], Malaysia [16, 44] or Iran [45], maxillofacial fractures caused by road traffic accidents are predominant. The high incidence of maxillofacial fractures through road traffic accidents in developing countries is due to many factors: poorly defined traffic rules, deliberately driving unapproved or uninspected vehicles and, not least, inadequate traffic lighting and marking of roads [17–20, 41–45]. A high frequency of road traffic accidents is also reported in developed countries with an increased population density, where such accidents are caused by the carelessness and non-compliance of drivers with the traffic rules [19–30]. In our country, the well-defined traffic rules, as well as the high penalties for their infringement, have lately led to a considerable reduction in the number of maxillofacial fractures caused by road traffic accidents. In contrast to the above publications, other authors report falling as the main cause of maxillofacial fractures [28, 46–48]. This can be due to effective prevention of interpersonal violence and traffic accidents in the geographical areas where the studies were conducted [48]. Global population aging should not be overlooked either, as the predisposition of elderly persons to facial trauma from falling is well known [40–48]. This is also evidenced by our findings.
Maxillofacial fractures caused by work accidents, domestic accidents or animal attacks had a low incidence in this study, being predominant in rural areas. These findings are consistent with those reported in the literature [1–25].
The mandible was the most fractured bone in this study, in accordance with the literature data [1–25] This finding is not surprising given the prominence of the mandible in the lower face, being directly exposed to trauma [1–25]. Regarding the most frequent location of the fracture line in the mandible, authors’ opinions diverge. According to our and other authors’ findings, mandibular angle fractures are the most frequent [48, 50], while other authors report the highest frequency of subcondylar fractures [23, 51], or paramedian mandibular fractures [53]. The location of the fracture line in the mandible varies depending on the type, texture, place of action, speed and kinetic energy of the wounding agent on the one hand, and on the position of the head and time of impact on the other hand [49–53]. This explains the discrepancies described in the literature related to this aspect [49–53].
In the midface, the most fractured bone was the zygomatic bone, which is supported by other authors [3–10, 17, 20, 27]. The zygomatic bone is the lateral pillar of the midface, absorbing most of the traumatic forces in this region [20, 27]. The fact that individuals tend to turn their head at the time of the impact in order to avoid frontal or ocular contact should also be considered [17–20, 27]. All this makes the zygomatic complex more susceptible to fracture [20, 27]. Contrary to our findings, other authors indicate the highest incidence of nasal bone fractures [43, 54] or orbital fractures [26, 34, 55]. The sagittal prominence of the nasal bones in the face explains the high incidence of fractures at this level [43, 54]. Biomechanically, the nasal bones have a decreased resistance to trauma [43, 54, 55]. The fact that in this study lateral orbital wall and orbital floor fractures were included as zygomatic complex fractures category, explains the small number of orbital fractures in our findings. In our study the majority of patients with multiple fracture lines in the midface caused by interpersonal violence is higher than those caused by RTAs. This is uncommon and rarely reported in the literature [1, 18, 24, 25]. Patients suffer multiple fracture lines in the midface usually secondary to RTAs due to the high kinetic energy developed, rather than human aggression [1, 18, 24, 25].
We believe that this study is providing vital information regarding the etiology and epidemiology of maxillo-facial fractures. This information can be used for managing the distribution of financial resources in healthcare services, preparing the doctors and nurses in order to relate to a certain type of the patients, and not least it can be used for implementing preventive measures regarding this particular pathology.
However there are several limitations that have to be taken into consideration regarding this study. A major limitation is that this study is a retrospective one. In these circumstances, the data taken from the observation sheets may be incomplete or erroneously recorded at the time of patient submission. A randomised controlled trial study should be done in the future to avoid these shortcomings. The possibility of people intentionally misreporting the cause of the trauma must also be considered. This occurs frequently in the case of inter-personal aggression, victims often indicate a different cause of trauma out of fear or to avoid certain legal implications.