JRMDS-I-283-2 Dentistry - Journal of Research in Medical and

Journal of Research in Medical and Dental Science
Volume 5, Issue 5, Page No: 87-94
Copyright CC BY-NC-ND 4.0
Available Online at: www.jrmds.in
eISSN No. 2347-2367: pISSN No. 2347-2545
Facial and Dental Trauma among Accident Victims
(Epidemiology, Diagnosis and Treatment)
Seyed Ali Mosaddad* and Maryam Erfani
Student Research Committee, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
DOI: 10.24896/jrmds.20175514
ABSTRACT
Dental and facial injuries may happen in many motorcycle accidents. In most cases, the injured person is referred
to a doctor immediately to assess the possible wound. Therefore, control and management of the damaged teeth
and preserving them is necessary to protect the damaged teeth. This study aim’s to investigate the maxillofacial
trauma by survey the victim of motorcycle accidents which are visited by Shahid Beheshti University of Medical
Sciences. Therefore, 330 patents in six month of 2015 were studied to gathering information. Moreover, most
cited manuscripts have been reviewed in detail to obtain treatment proposal procedure for this injured. The
result shows that the most frequent incident is a man motorcycle driver in midnight with 88 percent frequency in
contrast 12 female. 52 of patient had license but 87 percent did not use helmet at all. 51 percent of patient had
dental trauma and other just had facial problem. In this study, most of maxillofacial injuries are related to
complicated crown root fracture with 17 percent frequency, and after that the Luxation was the second frequent
injury with 16.4 percent. Finally, based on the result, some research topic proposed which could be useful to
researchers.
Key words: Epidemiology; maxillofacial trauma; motorcycle accidents.
HOW TO CITE THIS ARTICLE: Seyed Ali Mosaddad, DDS, Maryam Erfani, Facial and Dental Trauma among Accident Victims
(Epidemiology, Diagnosis and Treatment), J Res Med Dent Sci, 2017, 5 (5): 87-94, DOI: 10.24896/jrmds.20175514
Corresponding author: Seyed Ali Mosaddad, DDS
improper evasive action [3 - 4]. Thus, human
e-mail mosaddad.sa@gmail.com
factors have a significant part in road injuries and
Received: 22/06/2017
fatalities. The term accident marginalizes the role
Accepted: 21/09/2017
INTRODUCTION
In recent years, epidemiological research has
demonstrated that accidents do not occur
randomly so that there are factors leading to
higher risk of such events. Therefore, experts of
injury prevention prefer the term injury or
unintentional injury over accident [1]. Findings by
the Traffic Police indicate that inadequate forward
attention, following other cars at dangerously
close distances, and inobservance of right of way
are the major causes of traffic accidents in Iran.
Also, several important causes of motorcyclerelated accidents are perhaps incorrect handling,
speeding,
and
insufficient
attention
to
surroundings [2]. It has been demonstrated that
human factors play a major role in many traffic
incidents. By way of example, in several studies,
human factors were probable causes in about 93%
of accidents with factors including improper
lookout, excessive speed, inattention, and
of human beings and implies that human
endeavors are ineffectual in preventing unwanted
incidents. However, unanticipated traffic injuries
cannot
be
dismissed
as
random
and
unpredictable; they occur when a vulnerable
person meets an injurious agent in a hazardous or
compromised environment [5]. World Health
Organization express that over 1.2 million people
die in road accidents every year and about 50
million are injured globally. Also, over 90 percent
of these fatalities occur in countries with low- and
middle-income families, which have only 48
percent of the world’s registered vehicles.
Moreover, 46 percent of road traffic fatalities
pertain to vulnerable road users including
pedestrians, cyclists, and motorists and their
passengers [6]. Among them over the age of 40
years, especially the male population, traumatic
maxillofacial injury is the leading cause of not only
disability and morbidity but mortality as well [7 –
8].
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Further
research
indicates
that
beside
pedestrians, the most vulnerable users of traffic
networks may very well be motorcyclists, though
as indicated, other cyclists and motorists are not
immune to this type of injury [6 – 9]. Michael Ray
[10] study the treatment of maxillofacial trauma in
austere conditions. This research describes some
of the challenges and unique considerations a
surgeon and their team encounter in treating
these injuries in austere conditions. Studies have
established that pedestrian motor vehicle
accidents may be the most common cause of
serious pediatric head injury [5]. The reason these
groups are at risk to such extent is that they lack
sufficient physical protection [11]. Injuries that
involve high levels of force to the head, such as
high speed crashes, may result in a separation of
the medulla from the pons two components of the
brainstem almost always leading to instant
fatalities [12]. Seeing that unfortunately young
drivers and riders do not in many cases observe
speed limits measures must be taken to protect
them in other ways [13].
The Ministry of Health has cited research
performed in various universities in Iran
demonstrating that 51% of traffic incidents
leading to fatalities or hospitalization pertain to
motorcyclists whereas only 25% of such incidents
involve motor cars. This holds true despite the
strict laws recently imposed in Iran regarding
motorcycle helmet usage and motorcycle riding in
general. The former includes loss of tooth,
retrograde amnesia, and changes in mental state
while the latter consists of various neurological,
physical, cognitive, psychosocial, and emotional
effects. Motorcyclists undeniably not only lack
sufficient physical protection but are possessed of
poor conspicuity due to their small size and are
also subject to excessive risk taking [2]. According
to traffic laws in Iran, violations such as driving or
riding on the sidewalk, carrying unconventional
loads, illegal towage, driving in the wrong
direction or in restricted lanes, and having loud
exhaust pipe sounds will result in confiscation of
the respective vehicle for a one-week period for
the first violation and for a one-month period for
subsequent violations. Moreover, a 300,000 rial
fine is being imposed on unhelmeted motorcycle
riders and passengers. This can also be effective in
preventing traffic mishaps and related injuries,
specifically maxillofacial and brain trauma.
Consequently, they present a serious safety
hazard. By way of illustration, the injury rate in
Great Britain in 2002 for two wheeled motor
vehicles was 556 per 100 million vehicle
kilometers as opposed to 50 per 100 million
vehicle kilometers for car users [2]. Therefore, any
method that can increase their protection may be
significant in reducing motorcyclist road injuries.
Literature Reviews
According to [14] in a study conducted at the
National Study Center for Trauma and Emergency
medical Systems, the frequency of fatalities
related to motorcyclists deceased by 37 percent
after enactment of the Maryland mandatory
motorcycle helmet law. Studies performed on
motorcycle helmet usage have shown that
helmeted motorcyclists are less likely to
experience maxillofacial and head injuries
compared to motorcyclists not using helmets. It is
also significantly less likely for helmeted
motorcyclists to suffer from TBIs. Similar results
have been reported by other studies such as Lee et
al[9]; Huang & Preston [2]; World Health
Organization [13]; Crandon et al. [15]. A report on
the subject exhibited 29 percent to 73 percent
lower fatality rates when motorcycle helmets
were used [27]. It has been cited that for every
100 motorcycle fatalities, 37 lives may be saved
through helmet use [16]. Moreover, it has been
shown that some studies reporting no benefits or
small benefits for utilization of motorcycle
helmets
employ
erroneous
models
or
methodologies [11].
Ansari [17] investigates the maxillofacial fractures
in Hamedan province of Iran as a retrospective
study. Totally, 2268 patients with 3107 facial
fractures treated were analyzed between 1987
and 2001, retrospectively. The result shows that
men with 21-30 years of age sustained the most
facial fractures. The ratio of male to female was 4.
Most fractures were caused by motor vehicle
accidents (60%, 1360 pts), followed by falls
(18.9%, 429 pts), and assaults (10%, 227 pts).
Isolated mandibular fractures (52.6%, 1194 pts)
were most common, followed by isolated midfacial fractures (29.5%, 669 pts) and alveolar
process fractures (15.1%, 342 pts). 70.8% of
patients were treated by closed reduction, 17.8%
with open procedures and 11.4% using both.
Complications resulting directly from trauma
occurred in 5.5% of patients.
Zargar et al. [18] present an epidemiology study of
facial injuries during a 13 month of trauma
registry in Tehran. Their trauma patients who
were hospitalized for more than 24 hours and had
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sustained injuries within seven days from
admission were included in the study. Of the 8000
trauma patients, four hundred (5%) sustained
facial injuries. tHe result shows that male to
female ratio was 4.5 so on. Among them, 53.3%
were aged 11-30 years. Motorcyclists who wore a
helmet sustained facial fractures less often during
traffic accident than those patients who did not
wear helmet. Soft tissue injury and facial bone
fracture comprised 43.3% and 40.8% of facial
injuries, respectively. The majority of Soft tissue
injuries (79%) were located extra orally. The
mandible and nasal bone were the most
commonly fractured facial bones.
Seiedmoalemi and Dadkhah [19] present a study
of head and face injuries and helmet use and
hospitalization costs of motorcycle accidents. Data
in this retrospective descriptive-analytical study
was collected from 1626 patient how had
accidents and were hospitalized in the Alzahra
Hospital in 2010. The result how that accidents by
motorcycle comprised 31% of all the registered
motor vehicle accidents. The frequency of
motorcycle accidents was higher in October and
among 21-25 year-olds. The mean period of
hospitalization was 4.3 days and the mean of
hospital costs was about 9,000,000 Rials. The
frequency of head and face injuries was 51%
among all the injured motorcyclists, with 22%
among those wearing a crash helmet and 78%
among those not wearing a crash helmet (r =
0.267, p value = 0.009). A total of 35% of
motorcyclists reported wearing crash helmets.
Tuckett et al. [20] present a review study in
maxillofacial trauma field in the emergency
department. An electronic database search was
conducted in PubMed and Science Direct on
articles from 1970 to the present day. The key
search terms were Maxillofacial, Trauma, ATLS,
Advanced Trauma Life Support, EMST, Early
Management of Severe Trauma, Airway, Eye,
Ophthalmic and Management. The results show
that physicians are becoming increasingly exposed
to major maxillofacial injuries. Resuscitative
measures can be complex and require prompt
decisions especially in gaining a secure airway. A
proposed treatment algorithm for maxillofacial
trauma patients has been devised by the authors.
Cabalag et al. [21] investigate epidemiology and
management of maxillofacial fractures in an
Australian trauma centre. A retrospective records
review was performed for 980 patients who were
treated for MF fracture(s) from January 2009 to
December 2011. The results show that in total,
803 fractures from 500 patients were treated
operatively. Mandibular fractures were most
commonly treated surgically as 79.82%.
Postoperative complications occurred in 69 of 500
patients treated surgically as 13.8%, most
commonly due to infected metalware 3.20%.
Multiple fractures were associated with a higher
probability of requiring surgery and developing
postoperative complications, compared to isolated
fractures.
Connor et al. [22] report recent advances in the
management of oral and maxillofacial trauma.
They summarize recently published papers on
maxillofacial trauma in 2 widely read journals: the
British Journal of Oral and Maxillofacial Surgery
(BJOMS) and the International Journal of Oral and
Maxillofacial Surgery (IJOMS). The result shows
that most of the research in these journals
concerned mandibular fractures, particularly
those involving the condyle, but epidemiological
studies and midfacial fractures were also well
represented. Even though the incidence of facial
injury is high, it is difficult to collect data
particularly when long-term evaluation is
required, as rates of compliance and attendance at
follow up tend to be low.
Bazargani et al. [23] present a review literature of
95 articles about epidemiological patterns of road
traffic crashes in Iran from 1996 to 2014. The
result show that a large number of severe road
traffic crashes RTCs occur due to collision of two
or more vehicles and most of the victims are males
aged between 30 and 39 years. Moreover, it is
observed that male pedestrian, drivers and
passengers are more likely to be severely injured
in comparison to females. One of the most
prevalent causes of death among adults involved
in the RTCs were head injuries and the majority of
deaths occur prior to hospitalization. Mortality
rates for RTCs are higher in summer, especially
during midnight among all age groups. The most
common individual and environmental risk
factors associated with RTCs include lack of
attention, getting trapped in the car, listening to
music, fatigue and sleepiness, duration and
distance and negligence of seatbelt usage while
driving.
Rezaei et al. [24] present a study in field
epidemiology of maxillofacial trauma in a
university hospital of Kermanshah, Iran. They
record of 1727 patients were reviewed
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retrospectively. Data collected included patients’
name, sex, age, date of admission, etiology, type of
facial injury, associated non-facial trauma and
treatment modalities. Their result show that 1096
patients sustained only a soft-tissue injury. 631
patients had skeletal fractures. The significant
majority of patients (78%) were male and the
others were female (22%). The mean ages of
males and females were roughly similar (28.7 ±
12.5 for males versus 29.7 ± 15.4 for females).
Most patients were between 21 and 30 years old.
Motor vehicle accident was the major cause of
trauma (74.8%) followed by assault (13.2%) and
fall (8.3%). Nasal fracture was the most frequent
trauma (45.5%), followed by mandibular (29%)
and zygomatic (24.9) fracture. Central nervous
system was the commonest associated trauma.
72% of mandibular, 87% of maxillary and 84.8%
of zygomatic fractures were reduced via open
reduction and rigid internal fixation.
Dean et al. [25] ask a critical question is treating
oral & maxillofacial trauma profitable? They
introduce an analysis of hospital and surgeon
reimbursement at an academic medical center.
Their data was collected for patients who were
seen for primary trauma management by the
department of oral and maxillofacial surgery
between June 2011 and July 2014. The result
show that a total of 169 patients met the inclusion
criteria. There was a statistically significant
difference in both the percent of costs recouped
and the actual profit. The average percent of costs
recouped was 230% for the VCUHS, while OMS
only recouped 47% of costs. Finally, they
concluded that in their medical center,
maxillofacial trauma yields a net profit for the
hospital and a net loss for the operating surgeon.
Reich et al. [26] present a study in title
maxillofacial trauma underestimation of cervical
spine injury. Their results shows that 94.3% of
patient suffered from cranio maxillofacial injuries
only, 4.4% from cervical spine injuries only, and
1.3% from both injuries. In this study cohort the
most prevalent craniofacial injuries were 44%
midfacial and 22.6% skull base fractures. Cervical
spine injuries primarily affected the upper cervical
spine column 58.2% vs. 41.8%. Only 6% of cases
the cervical spine injury was diagnosed
coincidentally, and the cervical spine column was
under immobilized.
University of Medical Sciences. The sample was
non-fatally injured motorcyclists in Tehran which
its injured was related to facial and dental that
admitted to the emergency department. The time
period for the study was six month of 2015.
Moreover, all patient were included in study and
hospitalized patients were excluded from the
study. A questionnaire including age, sex, helmet
use, diver license, blood pressure were filled for
each patient by medically trained staff. Also, the
variables include damaged teeth type, number of
damaged teeth, reason of injury, location of injury,
and the time between the trauma and visit, were
studied. The results mean, frequency and
percentage were expressed. Kruskull Wallis and
Mann-Whitney tests were used in SPSS version 16
statistical software to compare dental injuries
based on demographic information in significant
level 95 percent. Hospital records were
individually reviewed to obtain a complete list of
injury diagnosis. Radiography and MRI results
were used to verify injury diagnoses when
available.
RESULTS
Epidemiology
After six mouth, finally the statistical population
was evolved to 330 patients which have
maxillofacial injury totally. All patients were
injured during an incident with motorcycle. From
the result, drivers constituted 79 percent and
passengers 18 percent of cases, and 3 percent had
unknown status. The average age of injured in
motorcycle incident with a dental trauma was 28
years, and also most of them was men constituted
88 percent. Obviously, most of the patient
including 87 percent don't use helmet at all.
However, the 13 percent helmet user just use a hat
for head protection. Facial injuries were
diagnosed in just cases, or 31 percent. Although,
18 percent has maxillofacial injury but just 51
percent in total has dental trauma. Moreover, just
52 percent of motorcycle drivers had motorcycle
driver license. But there is not significant
difference between facial and dental trauma with
and without license. All demographical status of
variables are presented in Table (1).
Moreover, the result shows that from 51 percent
patient just 618 teeth had a bad injury thereby
motorcycle accident.
MATERIAL AND METHODS
This study is an analytical survey which is
included 330 patients of Shahid Beheshti
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Table 1: The Demographic Status of Injured Motorcycle Incident by Sex, Helmet Use, Rider Status and License Driver
Demographic Variable
Sexuality
Driver License
Helmet Usa
Rider Status
Injury Type
Statuse
Male
Female
Yes
No
Yes
No
Driver
Passenger
Other
Facial
Dental
Maxillofacial
Percentage
88%
12%
52%
48%
13%
87%
79%
18%
3%
31%
51%
18%
Table 2: The Type of Injury and Epidemiology in Maxillofacial Trauma Patient
Maxillofacial Trauma
Alveolar fracture
Avulsion
Complicated crown fracture
Complicated crown root fracture
Concussion
Extrusion
Infraction
Intrusion
Lateral Luxation
Luxation
Root fracture
Subluxation
Uncomplicated crown fracture
Usually, the basic reason of injury was motorcyclecar crash with 62 percent frequency, though 29
percent had fall accident and just 9 percent had
motorcycle-motorcycle crash. 82 percent of
accident has happened in streets and 15 percent
in alley and 3 percent unknown. Also, all patient
before one month after accident had a visit by
doctor though 83 had it in the very day.
In this study, as is shown in Table (2), most of
maxillofacial injuries are related to Complicated
crown root fracture with 17 percent frequency,
after that the Luxation was the second frequent
injury with 16.4 percent. It is important that be
notice, most patient are encountered to Avulsion
with 15.8 percent frequency after Luxation and
Complicated crown root fracture. In addition,
rarely patient encountered to Intrusion with 2.7
percent frequency and also Subluxation with 3
percent frequency.
Diagnosis and Complications Trauma
One of the complications of trauma is bleeding.
The bleeding may be due to a simple trauma such
as beating, falling down, motorcycle accident or
tearing and perforation of organs which is caused
by a knife or bullet. Each of the organs of the body
including the brain and bones may be damaged or
Number
18
52
56
15
16
17
19
9
17
54
21
10
26
Percentage
5.5%
15.8%
17.0%
4.5%
4.8%
5.2%
5.8%
2.7%
5.2%
16.4%
6.4%
3.0%
7.9%
bleeding. In some cases, bleeding is not easily
visible.Bleeding of internal organs such as the
liver, kidney and spleen could be transferred into
the abdominal cavity. The only sign of this type of
bleeding, sometimes is reduction of intravenous
blood volume. Bleeding from the mouth, nose and
ears may be a sign of internal bleeding although it
is not very reliable. If after an accident and severe
bleeding, the injured not be immediately treated,
he might have the real risk of death. Therefore,
major bleeding control must be preceded by all
modes to preserve the heart and lungs damages. If
there is something such as bullet or stab in the
wound, or the wound is caused by bone fractures,
in most cases the object should never be removed
from the wound.It is recommended to avoid direct
pressure to open fractures or any object on the
wound. Initially the wound would be bandaged
and then it will be fixed with sufficient strength.
Sometimes by lifting the bleeding limbs, the blood
reduces and overall blood pressure rises. In order
to increase brain blood flow and to prevent shock,
it is better place the head along the body or lower
than it. Since the blood or other secretions of
impaired person may be contaminated with
infectious agents such as HIV viruses, the nurse
should prevent contact with the blood of injured
person. Using tourniquet is not recommended to
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stop bleeding, but in case of using, it should be
visible and letters should be written on the
forehead of the patient. Since there is always the
risk of cutting and bleeding by the method of
direct pressure to the wound, the use of a
tourniquet should be reduced to a minimum
Treatment and Medical Action to Maxillofacial
Trauma
Most dental injuries which menace motorcyclists
will occur during an accident in the anterior
region of mouth and upper maxillary. Tooth
structure includes hard tissues of the enamel,
dentin, cementum a tissue at the center which is
called dental pulp. Teeth, surrounded by
periodontal fibers are connected to the
surrounding bone. Damage can be related to one
or more of these structures. Dental trauma could
be classified on this basis. These injuries may be
variable from a crack in the enamel of the tooth to
getting out of their holes. All dental injuries
require proper evaluation, medical interventions,
periods of clinical and radiographic examination
for many years. In case of delay in taking
necessary actions after trauma, tooth prognosis
will reduce and even in some cases, despite
subsequent efforts, there will be no choice but to
extraction. One of the most urgent dental trauma
is the removal of the tooth from its cavity which
mostly happens during an accident. This situation
needs fast and correct treatment. Immediate
action includes rapid return of teeth to its holes to
prevent further damage to the periodontal fibers.
In case there was doubt about the correct
insertion of teeth, urgent action involves placing
implants in a suitable environment. This
environment for tooth transfer is HBSS Via span
Solution Salt Balanced Hanks which has a high
capacity to sustain the life of periodontal fibers for
a long period. Other proposed solutions include
milk, saliva, physiological saline and water. The
next step is early referral to the nearest dentist to
action treatment that could improve tooth
prognosis.
victim. One important area of research includes
feasibility studies for centralized systems for
accident patient and injury type data which also
show possible benefits of such systems in
planning for safer traffic. For the most part,
measures taken in Tehran to reduce traffic
fatalities, specifically traumatic maxillofacial
injuries, include legislation of stricter traffic laws
for all motorists and for motorcyclists in
particular, rigorous enforcement of traffic laws by
the Tehran Traffic Police, conduction of tutorials
on traffic safety and driving laws for traffic law
violators, conduction of workshops for the public
in order to elevate public awareness regarding
traffic affairs, decommission of obsolete vehicles,
and supply of free motorcycle helmets in
compliance
with
current
standards
to
motorcyclists.
All those who have suffered trauma should be
completely and accurately examined. This
examination should be divided into primary and
secondary levels. The first evaluation is
assessment to establish airway, breathing and
blood circulation of injured person. At later stage,
during the control pulse the efforts should
concentrated on controlling the bleeding and
evaluation of tissue perfusion with an emphasis on
refilling of the capillary vessels. In addition state
of consciousness of injured will be examined using
GCS or AVPU chart.In all cases, especially in small
bleeding, the patient's clothing will be taken off,
secondary assessment will carry out and then,
head to toe of injured person will be examined
carefully for diagnosed the other injuries.
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Without doubt, there is continuous need to
develop and execute new measures for reduction
of
trauma
incident
injuries.
Traumatic
maxillofacial injuries are of particular concern due
to the high fatality, disability, and morbidity rates
associated with them. Further research is
necessary for development of new techniques for
reduction of traffic incidents as well as cares their
4.
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