The maxillofacial trauma can be considered a devastating aggression found in trauma centers because of the emotional consequences and the possibility of deformity, in addition to causing economic impact on a health system (1).
This is a trauma of a multidisciplinary approach, involving mainly the specialties of otolaryngology, ophthalmology, plastic surgery, maxillofacial and neurosurgery.
An assault not only involves maxillofacial soft tissue and bone but also, by extension, can affect the brain, eyes, sinuses and teeth.
The diagnosis and treatment of these lesions achieved great progress in recent years. The facial trauma has become an unavoidable issue for physicians due to the fact that its frequency is increasing, especially in the last four decades, associated with increased motor vehicle accidents and urban violence (2,3).
Its etiology is heterogeneous and the predominance of one or another etiological factor is related to some characteristics of the population such as age, gender, social, urban and residential (4).
Studies show that men are more exposed to trauma due to the increased number of drivers of motor vehicles, for having the most contact sports, and have a social life more intense, therefore ingest more alcohol and other drugs (1,2). But in the last three decades, there is a growing incidence of trauma in women, usually aged up to 40 years due to their greater participation in activities that were predominantly male (5,6).
There are also reports in the literature that some population characteristics, such as living in rural and urban socio-economic or educational influence in the pathogenesis and severity of facial trauma (4,7,8).
This study aims to understand the epidemiological profile of patients who underwent surgery for maxillofacial trauma in a general hospital in the city of Blumenau, SC. METHOD
This research project was approved by the Ethics in Research at FURB, in the opinion no. 046/09.
From July 2004 to August 2009 were performed by one surgeon, 790 maxillofacial surgery at the Hospital Santo Antonio de Blumenau. The work was based on retrospective evaluation of records of patients diagnosed with facial fracture surgery in the same period.
This study included patients diagnosed with facial fractures and underwent emergency surgery or elective. The patients were from the Department of Maxillofacial Surgery, Hospital Santo Antonio Polyclinic or in Blumenau, SC.
Was used as an exclusion criterion, patients with facial trauma with only soft tissue involvement, those with simple fractures (linear) or dislocations that did not require referral to the surgical ward or were reduced in a bloodless himself in the emergency room.
Data collection was through the identification form, request for AIH (hospital admission), sheet evolution and surgical description. All surgeries were performed by one surgeon.
Among the information included: age (in years), sex, origin, marital status (single, married, divorced, widowed and other), occupational status (self, student, employee, housewife, unemployed, retired and others), education ( incomplete or complete primary school, secondary school or incomplete, complete or incomplete higher and illiterate), anatomical fracture site (mandibular, zygomatic, zygomatic arch, maxilla, nasal, orbital and frontal), number of bones involved (from one to five bones), etiology of trauma and the mean length of stay in days.
The variables are presented in tables and graphs with absolute and relative frequency. For continuous variables, we calculated the average and its standard deviation and median. RESULTS
We assessed 222 medical records of patients diagnosed with facial fractures. Most patients were male with 178 cases (80.1%) aged between 1 and 60 years (Table 1).
Although the majority of patients, 175 of the total (78.82%), being from the city of Blumenau, there is validity to neighboring cities as shown in (Table 1).
We also analyzed the marital status of surgical patients and found that unmarried individuals were more facial trauma that led to surgery, 148 in total, representing 66.6%. Eighty-six individuals studied have permanent employment (38.7%) (Table 1).
We made a connection between schooling and facial trauma and found that most patients were operated on only the first grade, 133 in total (61.7%) (Table 1).
As to etiology, in 79 patients (36%) the main cause that led to surgery was physical aggression, followed by traffic accidents with 41 cases (19%) and accidents involving motorcycle 27 (12%) (Table 2).
Facial bones in order of involvement were the mandible, nasal bone and zygoma (Table 2), most involving only one bone (Table 2). The median length of hospital stay was 1 day.
Analyzing the etiology of age, we found that of all assaults, 72 (91.1%) were in individuals over 18 years. Like all accidents, 81 (90%) were in this same age group (Table 3).
As to education, we found that people with less education have suffered more injuries and accidents, respectively 48 (60.7%) and 51 (56.6%) (Table 4).
According to the etiology and the number of fractured bones per patient can be seen in our study that only patients with a fractured bone were the main cause aggression: 72 cases (91.1%), while in patients with two or more fractured bones traffic accident was the most prevalent with 55 cases 75.3% (Table 5). DISCUSSION
Regarding gender, studies show that the most affected is the male with the following results, 80.7% of 788 patients (7), 78% of 164 (9) and 79.88% of 1024 patients (10) . Our results also showed male predominance with 178 cases (80.1%).
In another study, we observed a higher prevalence of facial trauma in men (84.9%), white (82.7%) and the mean age was 29 years of 513 patients (11).
Our study showed the predominance of involvement of patients between 20-29 years, with 88 cases (38), and the smallest number of operated cases occurred in the age group 0-9 years, 5 cases (2.5%) and median ages was equal to 27 years.
There are studies showing that the most affected age group was 20-29 years, with approximately two thirds (69.8%) of fractures occurred between ages 11-39 years (11). It coincides with our findings where we observed 84 patients (37.83%) aged between 20 and 29 years.
CHRCANOVIC BR et al. reported that most fractures occurred in adults aged 21-30 years (12).
In children and adults above 50 years, fractures were less frequent in our study. There were no surgical intervention in patients over 60 years.
There are studies that found that the low incidence of facial trauma in children and the elderly, due to the attention of family, stay at home and care of children and the characteristics of old age, as little activity social and sports activities, leaving little home and when they do they are accompanied (13,14).
As to occupation, MONTOVANI et al (2006) found a higher incidence in students (16.6%) and masons (11.2%). Our research shows that in 86 cases (38.73%) patients had permanent employment, in 53 cases (23.87%) were independent and 20 were students (9%).
In our study we observed a greater prevalence of surgery for facial trauma in patients who had low education level (illiterate and primary school) 63%. We assume that this had actually happened because the study was performed in hospital care with predominantly via the Unified Health System (SUS).
Profile of maxillofacial trauma is heterogeneous and the prevalence of etiologic factors is related to some characteristics of the population and the hospital studied, proven by our sample.
An accident involving the face have a rising incidence in the last four decades, the medical literature refers to the increase in motor vehicle collisions and urban violence as the main causes of these injuries, especially in young individuals (2,3).
A recent study pointed to automobile accidents as still being the main cause of severe facial trauma (15). However these findings are justified due to work being carried out in a regional referral center for trauma, thus affecting the types of trauma that the hospital served as the severity of the patients.
Regarding the aetiology of facial trauma, BRAUSTEIN PW (1957) studied accidents involving 2253 victims in 1000 and noted that 72.1% of injuries were caused by motor vehicles.
According MONTOVANI et al (2006), among the most common causes, stood out automobile accidents (28.3%), assaults (21%) and accidental falls (19.5%).
In the study of WULKAN et al (2005) with 164 patients, interpersonal violence was the most common cause overall (48.1%), followed by fall (26.2%). What confirms the tendency of most current studies to show an increased incidence of interpersonal violence, and suggest that this is the main etiology in facial trauma (16,17). As was proven by our study, where we found a predominance of the etiology of aggression with 79 cases (35.5%), followed by car accidents with 41 cases (18%), bikes with 27 cases (12%) and fall in 25 cases (11%).
When the work correlate the etiology of facial trauma with age, we noticed in some studies that the main cause among people 0-19 years was the decrease (17,18,19,20), another study found that both children (0-9 years) and adults older than 60 years the most common etiology was the fall, 46.8% and 40.7% respectively (11).
In our study, the same age (0-19 years) showed a prevalence of 19.4%, however when we look at just the age group 0-9 years, we found a prevalence of falls as an etiological factor quite significant with 80%. Some authors infer many factors that may favor for the fall will be significantly more frequent in older patients: the movement and balance are directly proportional to age, the conscience of the appearance of the face and its social importance increases with age (during a fall, children and adults considered to protect the face) (21).
Motor vehicle accidents were the leading cause of facial trauma in the age group 20-29 years (11). However, in this age group, we found a greater number of physical assault, 36 cases (42.8%). Recent studies also show that in the age group 20 to 39 years, the main cause is the interpersonal violence, 55.5% (9,22,23), confirming our findings.
When correlated with the age of 40 years or more, WULKAN et al. (2005) noticed that the fall also the primary mechanism of fracture by trauma (62.6%) that usually results from multiple causes pathological (eg osteoporosis).
Physiological mechanisms such as altered proprioception, weakness, tremor, and decreased reflexes facilitate the fall. Urinary tract infection and lung and alcohol use are also reported (22).
In our study we observed physical aggression being the main etiology in over 40 years, with 12 cases (25%).
Regarding the type of fracture, in their case studies, MONTOVANI et al. (2006) found 371 facial fractures simple - a single fracture in the face - (72.3%) 142 and multiple facial fractures (27.6%). In our study we also found a higher prevalence of simple fractures, with 193 cases (86.93%) according to the type of fracture, reported that the mandible was the most affected (35%), followed by the zygoma (24%) and nose (23%).
Already CHRCANOVIC et al. (2004) reported after study of 1,326 facial fractures in 911 patients, more than the facial bone fractured was the mandible, followed by the zygomatic complex and nose.
The incidence in our study was, in descending order: jaw 94 cases (35.8%), nose, 60 cases (22.9%), zygomatic 55 cases (20.9%), orbit 20 cases (7.6%) and jaw in 17 cases (6.4%).
A study of 2748 cases reported that in 1176 (42.7%) patients had midfacial fractures and 512 (18.6%) had fractures of the lower "jaw". Most patients with middle third facial fractures had zigomaticomaxilar region affected 422 (35.8%), while the region parasinfisária fractures were the most common jaw 156 (30.4%) (24).
Our study found 134 fractures of the facial middle third (57.51%), 94 patients with involvement of the lower third (40.34%) and 5 cases with involvement of the upper third (2.14%).
The series of WULKAN M et al. (2005) involved a large extent, high-energy trauma, resulting in their most mandibular fractures (21.9%), followed by Le Fort type fractures, facial or pan complex (17.8%).
MONTOVANI et al. (2006) correlated the single or isolated fractures of the attacks with low complexity, high complexity and fractures with motor vehicle accidents. The predominance in our study was to traumatic fractures isolated single or low-complexity, 193 cases (86.93%).
HAGAN EH, HUELKE DF (1961) reported that 55.8% of mandibular fractures were related to traffic accidents, 17% with physical aggression and 14% with other causes.
ROWE NL, KILLEY HC (1968) reported that 11.6% of fractures of the mandible were related to automobile accidents, motorcycle 15.8%, 18% with physical aggression and 12%, accidental falls.
We could relate the mandibular fractures and motorcycle accidents in 12 patients (12.76%), car in 17 patients (18.08%), assault in 36 (38.29%), fall in seven surgical patients (7.44%) and the remainder with various causes 22 (23.4%). CONCLUSION
We conclude that the epidemiological profile of 222 patients undergoing surgery for facial fractures performed by the specialty of maxillofacial traumatology at Hospital Santo Antonio in Blumenau, Santa Catarina 2004-2009 individual is male, aged 20-29 years old, single, low education and employee.
The most prevalent etiology was assault, involving only a fractured bone and the jaw bone most affected. BIBLIOGRAPHICAL REFERENCES
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1 Oral and Maxillofacial Surgeon, Hospital Santa Catarina and San Antonio de Blumenau - SC. Student, Medical University Regional Blumenau FURB.
2 Medical Student FURB.
3 Professor. Doctor.
Institution: Regional University of Blumenau - FURB. Blumenau / SC - Brazil. Mail Address: Frederico Santos Keim Street - Victor Konder, 99 - Apto 601 - Bairro: Victor Konder - Blumenau / SC - Brazil - Zip code: 89010-000 - Telephone: (+55 47) 9193-6583 - E-mail: firstname.lastname@example.org
Article received in February 11, 2010. Article accepted in March 26, 2010.