Traumatic injury is the most common cause of death in the last 10 years and still a significant health problem in all countries, in spite of the level of the socio-economic state. About 12,000 Egyptians died each year due to different types and etiological causes of trauma (El Shehaby et al. 2018). The human face often constitutes the first point of contact in various human interactions and is frequently the preferred target for blows in assault cases (El Shehaby et al. 2019). Maxillofacial trauma is thus a common presentation in accident and emergency departments either as an isolated injury or as a part of poly-trauma. These injuries may cause serious functional, psychological, physical, and cosmetic disabilities (Kapoor and Kalra 2012).
The present study is a descriptive hospital-based study that was carried out on 1221 trauma patients with maxillofacial fractures combined with closed head injury of both sexes referred to the Trauma Unit and Maxillofacial Surgery Department of Assiut University Hospitals (tertiary care hospital), Egypt, throughout the period from 1 January 2011 to the end of December 2016.
The epidemiological criteria revealed that maxillofacial fractures accounted for 4% of all trauma cases, and its peak was at the year 2011 and 2015; this result is slightly higher than that reported by Pillay et al. which reported the incidence of craniomaxillofacial fractures as 2.9% (Pillay et al. 2018), but lower than that previously reported (16%) in a similar study conducted in Australia (Shahim et al. 2006). The incidence of traumatic head injury (THI) associated with MFF in different countries around the world is greatly different, but the overall result is higher in males when compared with females; in the present study, it is 7:1; this result is in accordance with Patil et al. (2016). Other studies in the developed countries, the male/female ratio ranged from 2:1 to 4:1, which indicates the active participation of women in outdoor life activities than in developing countries (Gassner et al. 2003).
Considerable variations between developing and developed countries may be present but still male outnumber female by more than 2 to 1; this may be attributed to the higher percentage of women in developed countries who participate directly in economic, social, and cultural activities, and therefore, they are consequently susceptible to violence, traffic accidents, and sports accident (El Shehaby et al. 2018). Men usually outnumber women in developing countries due to their mobility, more frequently involved in stronger physical, violent activities, and motor vehicle crashes and often sustain more severe injuries compared with females (El Shehaby et al. 2019). In the present study, the commonest age group among the injured cases was 18–40 years; it was suggested that this is the age of adolescence and adulthood where persons frequently carelessly drive motor vehicles and practice dangerous exercises and thus exposing themselves to all types of violent trauma (Thorén et al. 2010). This agrees with the result of Mijiti et al. (2014) that showed most cases exposed to THI concomitant with MFF are men between 20 and 39 years.
The main etiology for craniomaxillofacial fractures over the reported 6-year period was road traffic accidents (69.7%); this finding is supported by several studies where traffic accidents were the most prevalent etiology of facial trauma (Samieirad et al. 2015). The second etiology was fall then followed by interpersonal violence which was the third responsible etiological cause; this result is similar to Sbordone et al. 2018. Alternatively, other recent metacentric retrospective studies from Southern Italy in 2018 reported that the vast majority of cases were due to violent assaults followed by road traffic accident (RTA) then falls (Khan and Arif 2005). Road traffic accident is the leading cause of traumatic injuries in developing countries, while interpersonal violence is the leading cause in developed countries (Pillay et al. 2018). The possible causes for this in Egypt are multifactorial that may be due to bad road conditions and poor road lighting along with lack of adequate public transport systems all contribute to increased trauma. The primary reasons for the increase in fatalities and injuries from traffic crashes in developing countries are simply the rising number of motor vehicles, economic growth associated with increased mobility, need to travel for employment, lack of traffic police manpower to implement existing laws, sudden urbanization as well as availability of easy loans for middle and low socio-economic population, and lack of awareness of the use of helmets. These findings should announce the need for better road traffic awareness among masses (Fasola et al. 2003).
Falls in the form of fall from heights and fall on the ground are considered as persistent hazards met in all communities and occupational settings. It is frequently encountered in accidents, suicides, and rarely in homicides (Hagga et al. 2016). The extent of injuries sustained due to fall from heights varies depending on the falling height, composition of the impact surface, intermediate objects encountered during the fall process, rate of deceleration, position of the body on landing, and individual factors such as age, body weight, pre-existing disease, and also age of the person (child, adult, elderly). In the case of falls, craniocerebral trauma (head injury) is the primary cause of mortality among skeletal injuries. Among soft tissue injuries, injury to the brain followed by the liver, lung, and spleen was frequent (Sasaki et al. 2009).
Injuries are caused by intentional and unintentional causes; intentional injuries occur with purposeful intent and include homicide, suicide, domestic violence, sexual assaults, bias-related violence, and firearms. Unintentional injuries are injuries that occur without purposeful intent (Sasaki et al. 2009). In the present study, accidental manner of injury was a major manner of craniomaxillofacial fractures followed by homicidal manner, while suicidal attack represents less than 1% only; this can be explained by the fact that road traffic accidents (as a major responsible for accidental manner) outnumbered interpersonal violence.
In agreement with some studies (Kapoor and Kalra 2012; van den Bergh et al. 2012), mandibular fracture constitutes a major portion of maxillofacial fractures (49.7%) because of its prominence and unique mobility, and though a very strong bone, mandible has several areas of weaknesses, followed by fracture maxilla (19.2%), then fracture zygoma (16.8%), and lastly frontal bone and ethmoid fractures (9.1% and 5.2%, respectively). Zygoma was found to be the main bone involved in the maxillofacial region in Bajwa et al. (2012) while the maxilla and nasal bones to be the main bones involved in maxillofacial trauma in Haug et al. (1992).
The Glasgow Coma Scale (GCS) is a reliable tool for the evaluation of mental status, potential brain injury, clinical conditions, and prognosis of the traumatized patients on admission in the emergency department (Majdan et al. 2015). The GCS provides a reproducible index of neurologic status based on numerical values that are ascribed to eye-opening, best verbal response, and best motor response. However, it is not a substitute for a detailed neurologic examination (Vrinceanu and Banica 2014). On the basis of GCS scores of the patients, about half of the cases (50.7%) had mild THI, 46.0% were of moderate THI, and only 3.3% of the cases had severed THI. The high incidence of a mild type of head injuries associated with maxillofacial injuries is in agreement with Hasnat et al. (2017). However, another study showed a significantly greater incidence of moderate type of head injuries associated with maxillofacial injuries (Senthilkumar et al. 2017).
Oral and maxillofacial surgeons who undertake treatment of facial injuries should have the responsibility for repair of the aesthetic defect, restoration of function, and reduction of the period of disability. The choice for treatment concepts in the current study is 50% were treated surgically and 50% of cases were treated conservatively in the university hospital. However, another study reported a higher percentage of cases treated surgically (66.08%) (Vrinceanu and Banica 2014). Approaches to the craniomaxillofacial fractures were according to the clinical guidelines including non-displaced fractures were managed conservatively with providing acceptable functional and esthetic results, displaced fractures were managed surgically by open reduction (repositioning of the displaced segments into anatomic position), and rigid internal fixation with mini plates (Perry 2010; Hailemichael et al. 2015).
There was a significant statistical association between age and etiology of MFF (RTA, falls, violence, and firearm injuries) (p < 0.05); the higher occurrence of RTA among males than females (72.7% males, 47.9% females) while falls were the main etiology among women (41.8% in female, 11.4% in male) as reported in previous studies (Chalya et al. 2011) because more men than women are commuting.
The trend of maxillofacial fractures and its different patterns from the year 2011 to 2016 were the highest in 2011 (21.5%) (the year of 25th January Revolution); this can be explained by that the 25th January Revolution aroused some political conflicts and members of different political groups that used violence and aggressive behavior to express their opinions in political struggles subsequently increased the frequency of violent assaults and the trauma incidence in general, while in the year of 2014, the Egyptian community retained its political stability and the police forces retained its control ability of violence with marked restriction in the violent assaults and fights (El Shehaby et al. 2018).
