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Maxillofacial fractures associated with accidents Ruslin, Muhammad

2019

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Download date: 26. Sep. 2021 Maxillofacial Fractures Associated with Accidents: Epidemiology and Consequences - Fractures Associated Maxillofacial

Maxillofacial Fractures AssociatedMaxillofa cwithial F rAccidents:actures EpidemiologyAssociated and wit hConsequences Accidents: Epidemiology and Consequences Muhammad Ruslin

MUHAMMAD RUSLIN MaxillofacialMaxillofacial fractures fractures associated with accidents: EpidemiologyEpidemiology and consequences

Muhammad Ruslin

The studies presented in this thesis were performed at the departement of Oral and MaxillofacialThe studies presented in this thesis were performed at the departement of Oral and Maxillofacial Surgery, VU University Medical Center / Academic Centre for Dentistry Amsterdam (ACTA),Surgery, VU University Medical Center / Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands. Amsterdam, the Netherlands.

Financial support for publication of this thesis was provided by : Financial support for publication of this thesis was provided by : Academic Centre for Dentistry Amsterdam Academic Centre for Dentistry Amsterdam

Cover design : M. Ruslin Cover design :: M. Ruslin Layout design : Asyraf Afif Alfian, M. Ruslin Layout design : Asyraf: Asyraf Afif Alfian, M. Ruslin Designer : van der Linden Grafische Dienstverlening Designer : van: van der Linden Grafische Dienstverlening Printer by : van der Linden Grafische Dienstverlening PrintedPrinter byby : van: van der Linden Grafische Dienstverlening

door ISBN : 978-90-90313970-9 ISBN :: 978978-90-9031397-9-90-90313970-9 Muhammad Ruslin Copyright 2018, M. Ruslin, Amsterdam, the Netherlands Copyright 2018,2018, M. Ruslin, Amsterdam, the Netherlands geboren te Pangkajene, Indonesië All rights reserved. No part of this publication may be reproduced or transmitted in any form or by anyAll rights reserved. No partpart of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage andmeans, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without prior permission from the author. retrieval system, without prior permission fromfrom thethe author.author.

VRIJE UNIVERSITEIT

Maxillofacial fractures associated with accidents:

Epidemiology and consequences

ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, of gezag van de rector magnificus prof.dr. V. Subramaniam, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Tandheelkunde op maandag 14 januari 2019 om 13.45 uur in de aula van de universiteit, De Boelelaan 1105

doordoor

Muhammad Ruslin geboren te Pangkajene, Indonesië geboren te Pangkajene, Indonesië

promotor: prof.dr. T. Forouzanfar promotor : prof.dr. T. Forouzanfar copromotoren: prof.dr. D.B Tuinzing copromotoren: prof.dr. D.B Tuinzing dr. P. Boffano dr. P. Boffano

promotiecommissie: prof.dr. D. Wismeijer prof.dr. E.A.J.M. Schulten prof.dr. B.J. van Royen prof.dr. Y.Y. Harmas dr. E.M. van Cann paranimfen: Diandra Sabrina Natsir Kalla Faqi Nurdiansyah Hendra

Contents

Chapter 1 : General introduction 1

Chapter 2 : Maxillofacial fractures associated with motor vehicle accidents: a 11 review of the current literature

Chapter 3 : Motor-vehicle accidents related maxillofacial injuries: a multicenter 21 and prospective study

Chapter 4 : Maxillofacial fractures associated with sport injuries: a review of the 33 current literature

Chapter 5 : Sport-related maxillofacial fractures 45

Chapter 6 : Sport related maxillofacial fractures: a multicenter and prospective 55 study

Allah will exalt those who believe among you, and those who have Allah will exalt those who believe among you, and those who have Chapter 7 : Dental trauma in association with maxillofacial fractures; 69 knowledge, to high ranks. knowledge, to high ranks. an epidemiological study

Al-Mujaadilah 11 Al-Mujaadilah 11 Chapter 8 : The Maxillofacial Injury Severity Score (MFISS) and Facial Injury 82 Severity Scale (FISS) as a predictor brain injury with maxillofacial fractures patients

Chapter 9 : The use of neuron-specific enolase to predict brain injury in 91 motorcycle crash patients with maxillofacial fractures: a pilot study

Chapter 10 : The influence of helmet on the prevention of maxillofacial fractures 101 sustained during motorcycle accidents

Chapter 11 : Summary, General discussion and Conclussion 111

Chapter 12 : Samenvatting 123

Acknowledgements 131

List of publications 137

Curriculum vitae 143

Contents

Chapter 1 : General introduction 1

Chapter 2 : Maxillofacial fractures associated with motor vehicle accidents: a 11 review of the current literature

Chapter 3 : Motor-vehicle accidents related maxillofacial injuries: a multicenter 2211 and prospective study

Chapter 4 : Maxillofacial fractures associated with sport injuries: a review of the 3333 current literature

Chapter 5 : Sport-related maxillofacial fractures 4455

Chapter 6 : Sport related maxillofacial fractures: a multicenter and prospective 5555 study

Chapter 7 : Dental trauma in association with maxillofacial fractures; 69 an epidemiological study

Chapter 8 : The Maxillofacial Injury Severity Score (MFISS) and Facial Injury 8281 Severity Scale (FISS) as a predictor brain injury with maxillofacial fractures patients

Chapter 9 : The use of neuron-specific enolase to predict brain injury in 9911 motorcycle crash patients with maxillofacial fractures: a pilot study

Chapter 10 : The influence of helmet on the prevention of maxillofacial fractures 101 sustained during motorcycle accidents

Chapter 11 : Summary, General discussion and Conclussion 111111

Chapter 12 : Samenvatting 123

Acknowledgements 131131

List of publications 137137

Curriculum vitae 143143

Chapter 1

General Introduction

ͳ General Introduction Maxillofacial fracture is defined as any physical insult caused to the face. It occurs quite commonly after trauma and is often encountered in emergency medicine. If not properly managed, it can negatively influence patients’ psychosocial and functional activities. Due to the specificity of this anatomical region, maxillofacial injuries are serious clinical issues: it is in this region that the crucial organs are placed and the digestive and respiratory systems begin. For this reason, injuries in this part of the body are regarded as serious dysfunctions.

Maxillofacial injuries have various causes: trafﬁc accidents, falls, assaults, and sports injuries. They can be isolated or combined with other injuries. Thorough knowledge and understanding of the epidemiology and consequences of these injuries is fundamental to the development of health services and the adoption of new methods for preventing injuries.1-11

Epidemiology of Maxillofacial Fractures Globally, there have beed numerous epidemiological studies of maxillofacial fractures, especially in the trauma, surgical, dental, and medical literature.11 Reports on developments in treatment modalities in surgery and dental procedures vary according not only to the geographic area in which the research is conducted and to the socioeconomic status of the patient group, but also to the period of investigation.1-10 A range of studies have investigated the epidemiological features of maxillofacial fractures in various population groups around the world1-12 Some have found that maxillofacial fractures are more common among young adults, particularly males in the third and fourth decades of life, often because they are involved in outdoor activities or reckless driving.13,14 One study found that the largest proportion of injuries occured in those whose ages ranged from 16 (48%) to 30 (68%).15 Another study also found that 68.6% of its study population lay in the 20-40 age range.13

With regard to the types of fractures, a systematic review published in 2013 found that mandibular fracture was the most common fracture, accounting for 59.2% of the total.10,16 In contrast, other studies in the western world found that nasal bone fractures and zygomatic complex fractures were more common.5,17 Several studies found that the main fracture site in the mandible was the body, which accounted for 40% of the total number of mandible fractures.5,10,17 In the middle third, the zygoma was the most involved site.4 The relative predominance of the facial structure involved has also been affected by a shift in the etiology of the injury, where an increase in the number of high- speed motor vehicle accidents produced a shift from mandibular fractures to midface and craniofacial fractures.18-23 While reports in low- and middle-income countries show that traffic accidents are the main cause of maxillofacial fractures,9,19-22 data from high-income countries indicates that the main cause lies in assaults.16,17,23-25

ʹ Although assault is also becoming the most frequent cause in many low- and middle-income countries, motor vehicle accidents (MVAs) are still among the world’s most frequent causes of facial fractures.2,19,20 Traffic accidents account for 34.42–80.14% of all skeletal and soft tissue 1 injuries in the facial area.18 The recent literature shows clear differences between the incidence of MVA-related facial fractures in high-income countries (20% in Japan, 35.2% in the Netherlands, 11% in Ireland) and low- and middle-incomes countries (72–85% in India, 46.7% in China).1

Sport are another important causes of maxillofacial injury. Approximately 5% of all mandible fractures and 9% of fractures in the upper two-thirds of the face are caused by sport. Direct body contact accounts for the majority of sports-related injuries, the most commonly associated soft tissue injuries being found in the head and neck region.26 Sport-related accidents are also responsible for approximately 10% of all midfacial trauma. In their study of sport-related injuries, Elhammali et al.22 found a significant prevalence of the mid-facial complex (67%), followed by the mandible (29%) and skull base (4%).16,17,22 In their review of sports-related maxillofacial trauma, Kunamoto et al.16 suggested that a difference between the types of sports and the frequency and type of fractures.16 While sports such as football, baseball, and hockey accounted for a high percentage of facial injuries among young adults,16,17,22 horse riders most commonly incurred fractures of the zygomatic bone (40%), and rugby players most commonly incurred mandible fractures (65%).17 As no data are currently available on sport-related maxillofacial fractures in the Netherlands, it is important to evaluate the possible relationships between the types of sport practiced, the frequency, and nature of patients’ bone fractures.

Consequences of Maxillofacial Fractures Trauma to the facial region can cause injury to the dentition, facial soft tissues, and skeletal components of the face such as the mandible, maxilla, zygoma, naso-orbitoethmoidal complex, and supra-orbital structures.27 As facial traumas often underlie further aesthetic disturbances,11 cosmetic deformities can be expected after nasal and naso-orbito-ethmoidal injuries.26 Victims of facial injuries can sustain scars or disfigurements, with their resultant emotional and psychological impact, such as posttraumatic stress syndrome and depression, which are common after facial injuries have been sustained.28 Due to the centrality of the facial region as a key factor in human identity, esthetics, and general well-being, the scarring caused even by minor facial injuries can be costly and have a personal impact on the injured person.14 Before or after the reduction of a fracture, vision-related complications can also be an issue, especially after a high Le Fort fracture. Intraorbital or retrobulbar hemorrhage or damage to the optic nerve caused by bone fragments can all lead to blindness, enophthalmos, and diplopia. While patients with zygomatic fractures may suffer from trismus, other forms of maxillofacial injuries can also cause paranasal sinus fractures.26

͵ Fracture of the alveolar process often causes damage to the soft tissues and teeth, increasing the severity of craniofacial injuries.16 Various published article have reported on dental injury in maxillofacial fracture, which occurs mainly in childhood and adolescence.29-36 Improper rigid fixation of fracture segments will result in malocclusion, especially in patients with anterior open bites and/or class III fracture patterns.26 A Study by Abbasi et al.27 found the presence of unerupted mandibular third molars to be associated with an increased risk for mandibular angle fracture.27 Facial fractures can influence the treatment of dental injuries, as facial swelling may not always allow dental treatment after fracture reduction. Premature tooth loss may result.30-36

Several studies on facial fractures found an association between traumatic brain injury (TBI) and the trauma resulting from maxillofacial injuries.37 The presence of brain injuries in patients with a maxillofacial fracture is a life-threatening condition. Over 50% of patients with these fractures have multisystem trauma that requires special attention. Accurate diagnosis of TBI can be problematic: a physician examining these injuries must assess the patient rapidly and according to a consistent methodology. Diagnosis should be prompt, and the treatment should be appropriate.37

In recent years, the Glasgow Coma Scale (GCS) has been seen as the gold standard for assessing the level of consciousness in patients who have sustained traumatic brain injury after trauma.38 However the GCS scale lacks the specificity necessary for determining the exact magnitude of any brain injury sustained during such an event. Such injuries are also difficult to assess using clinical techniques such as magnetic resonance imaging or by computer tomography.39 This explains the development of Neuron Specific Enolase (NSE) to evaluate neuronal damage. A protein-based enzyme found primarily within neurons, NSE is commonly used to assess the grade of neuronal damage after trauma.40-43 As increased concentrations of NSE can be measured in the cerebrospinal fluid and in the peripheral blood after neuronal damage, it provides a quick and reliable laboratory indicator of the degree of brain-cell damage sustained after trauma.44

There are several severity for assessing the severity and probable outcome of injury,44-47 the most commonly used classification scores being Facial Injury Severity Scale (FISS)15 and Maxillofacial Injury Severity Score (MFISS).44,46 Based on the Abbreviated Injury Scale (AIS), these two scoring systems combine the Injury Severity Score parameters of maxillofacial function and appearance (e.g., limited opening of mouth, malocclusion, facial deformity).44-46 Although the FISS also classifies the laceration of both facial soft tissue and bone, the classification of bones is not sufficiently detailed, and cannot be used to distinguish between displaced and comminuted fractures.45,46 As well as taking account of anatomic damage, subsequent scoring systems such as the MFISS also take account of the impairment of maxillofacial function and facial appearance, which can reflect the effect on quality of life (QoL) caused by maxillofacial injuries.

Ͷ In some high-income countries, TBI was found to be a major cause of cyclists’ deaths and of severe morbidity involving the head area as the impact zone.39-41 The exact pattern of such head injuries depends on the magnitude and direction of the impact force and the trauma site.48 1 Althought previous studies assessing motorcycle accidents found that the risk of head and brain injuries was significantly lower in riders who wore helmets than in those who did not, there is currently very little information on the location and pattern of craniomaxillomandibular skull injuries in cyclists (as distinct from motorcyclists) who wear helmets.

The prompt determination of brain injury in patients with maxillofacial fracture is crucial to improving their survival and recovery. If a patient has multiple-system trauma or other pressing medical concerns, facial frcatures may initially go unnoticed. In view of the consequences of untreated mild brain injury, it is crucial to detect any brain injuries in maxillofacial trauma patients at an early stage. It is also important to establish the incidence of maxillofacial fractures associated with traumatic brain injuries.1-10

Prevention of Maxillofacial Fractures Prevention modalities vary according to age and the cause of injury. The majority of injuries in children occur during unstructured play and result in minor facial trauma. General provisions such as safe play areas with soft surfaces will minimize falls and their impact. In older children, injuries in organized sport will be minimized by the provision and wearing of appropriate safety gear..29

Some types of sport carry an increased risk of injury. In contact sports, custom-made molded mouthguards have a proven efficacy in reducing both dental and oral trauma, and also in minimizing concussion after lower-jaw impacts. Since mouthguards become compulsory in the United States and New Zealand for high-school and college football and rugby players, the proportion of face and mouth injuries is estimated to have fallen from 50% to < 0.5% of all football- related injuries.29

Preventing maxillofacial injuries is important to improving the quality of life of the people involved, and also to reducing the socioeconomic costs of traffic injuries. Traffic-related trauma continues to decrease, due not only to the advent of better safety in automobiles (such as airbag and the use of seat belts) but also to the enforcement of laws on alcohol and speed limits.48-54 With regard to motorcycle accidents, we should acknowledge the crucial role of helmets. Recent studies have shown that wearing a helmets can reduce the overall risk of head and brain injuries by 63%–88% and can also reduce injuries to the upper and mid-facial area.41-51,53 It has also been reported that wearing a standard, good-quality motorcycle helmet reduces the risk of mortality by 40% and the risk of serious injury by over 70%.1-10

ͷ Aim of the Study Reports worldwide on the incidence and epidemiological causes of maxillofacial fractures1-10 show that the greatest cause are traffic accidents and sport-related accidents. Maxillofacial trauma especially in high-energy trauma is often associated with injuries to the cranium. While it remains a challange to assess the exact extent of any brain damage caused by traffic accidents or other traumatic injuries.48,54 It may now be possible to do so using NSE serum.40-43 The use of trauma score and severity grade in trauma studies can also provide the basis for determining treatment strategy, guiding anesthetization and surgery, predicting the survival probability of the injured patients, and predicting the impact of maxillofacial fractures on future health status.44-47 This study therefore evaluated the maxillofacial fractures related to various types of accidents. We also investigated other factors, such as etiology, complication, assessment, and prevention of this type of fracture.

Objectives: • To understand the distribution and characteristics of MVA-related facial injuries and sport accidents worldwide, a review of the literature was performed. The demographics and patterns of MVA-related maxillofacial fractures and sport accidents were also studied in a multicentre study. • Retrospectively, we investigated the incidence and associated factors of dental trauma in all patients presenting with facial trauma accompanied by dental injury. • As well as investigating NSE serum levels in patients who had sustained maxillofacial fractures during motor-vehicle accidents, we investigated the accuracy of neuron-specific biomarkers in detecting mild brain injury. • To our knowledge, the literature contains less information on the use of MFISS and FISS in predicting TBI. We therefore assessed the value of MFISS and FISS in detecting brain injury in patients with maxillofacial fractures. • In motorcycle accidents, different helmet designs (i.e., full-coverage and half-coverage helmets) can produce different effect on patients who sustain maxillofacial fractures. This study therefore assessed the effects of half-coverage helmets worn in motorcycle accidents by comparing helmeted and unhelmeted motorcyclists who had sustained maxillofacial fractures during motorcycle accidents.

͸ References 1. Yamamoto K, Matsusue Y, Horita S, Murakami K, Ueyama Y, Sugiura T, Kirita T. Maxillofacial fractures of pedestrians injured in a motor vehicle accident. Craniomaxillofac Trauma Reconstr 2013;6(1):37–42. 2. Boffano P, Kommers SC, Karagozoglu KH, Forouzanfar T. Aetiology of maxillofacial fractures: a review of published studies during 1 the last 30 years. Br J Oral Maxillofac Surg 2014;52(10):901–906. 3. Kommers SC, van den Bergh B, Boffano P, Verweij KP, Forouzanfar T. Dysocclusion after maxillofacial trauma: a 42 year analysis. J Craniomaxillofac Surg 2014;42(7):1083–1086. 4. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Diplopia and orbital wall fractures. J Craniofac Surg 2014;25(2): e183–e185. 5. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116(3):275–280. 6. Fasola AO, Lawoyin JO, Obiechina AE, Arotiba JT. 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A literature review of sports-related orofacial trauma. Gen Dent 2004;52(3):270–280. 17. Tanaka N, Hayashi S, Amagasa T, Kohama G. Maxillofacial fractures sustained during sports. J Oral Maxillofac Surg 1996;54(6): 715–720 18. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9543 cases with 21067 injuries. J Craniomaxillofac Surg 2003;31(1):51–61. 19. Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, Vesnaver A, Konstantinović VS, Petrović M, Stephens J, Kanzaria A, Bhatti N, Holmes S, Pechalova PF, Bakardjiev AG, Malanchuk VA, Kopchak AV, Galteland P, Mjøen E, Skjelbred P, Grimaud F, Fauvel F, Longis J, Corre P, Løes S, Lekven N, Laverick S, Gordon P, Tamme T, Akermann S, Karagozoglu KH, Kommers SC, Meijer B, Forouzanfar T. European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119(5):499–504. 20. 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A etiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40(12):165–169. 24. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(2):166–170. 25. Bali R, Sharma P, Garg A, Dhillon G. A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India. J Inj Violence Res 2013;5(2):108–116. 26. Aktop S, Gonul O, Satilmis T, Garip H, Goker K. Management of Midfacial Fractures. A Textbook of Advanced Oral and Maxillofacial Surgery. Chapter 15:415–444. 27. Abbasi MM, Abbas I, Khan N, Shah SMH, Hameed H, Shad S, Zulfiqar K. Frequency of unerupted mandibular third molar in mandibular angle fractures. J Ayub Med Coll Abbottabad 2012;24(1):30–32. 28. Lee K. Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr 2012;5(4):213–222.

͹ 29. Barker R, Hockey R, Spinks D, Miles E. Facial Injury. Queensland Injury Surveillance Unit 2003;79:1–6. 30. Thoren H, Numminen L, Snall J, Korni E, Lindqvist C, Lizuka T. Tornwall J. Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg 2010;39(8):774–778. 31. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg 2009;69(8):1680–1684. 32. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with maxillofacial fractures. Dental Traumatol 2013;29(4): 285–290. 33. da Silva AC, Passeri LA, Mazzonetto R, De Moraes M, Moreira RW. Incidence of dental trauma associated with facial trauma in Brazil: a 1-year evaluation. Dent Traumatol 2004;20(1):6–11. 34. Gassner R, Bosch R, Tuli R, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries. Implication for prevention. Oral Surg Oral Med Oral Pathol Ral Radiol Endod 1999;87(1):27–33. 35. Roccia F, Boffano P, Bianchi FA, Ramieri G. An 11-year review of dental injuries associated with maxillofacial fractures in Turin, Italy. J Oral Maxillofac Surg 2013;17(4):269–274. 36. Iso-Kungas P, Tornwall J, Suominen AL, Lindqvist C, Thoren H. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofacial Surg 2012;70(2):396–400. 37. Salentijn EG, Peerdeman SM, Boffano P, van den Bergh B, Forouzanfar T. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 2014;42(6):705–710. 38. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81–84. 39. Kobeissy FH, Ottens AK, Zhang Z, Liu MC, Denslow ND, Dave JR, Tortella FC, Hayes RL, Wang KKW. Novel differential neuroproteomics analysis of traumatic brain injury in rats. Mol Cell Proteomics 2006;5(10):1887–1898. 40. Hayes RL. Biochemical markers of brain injury: applications to combat casualty care. Paper presented at: the RTO HFM Symposium on combat casualty care in ground based tactical situations: Trauma technology and emergency medical procedures; August 16-18, 2004;16–8; St. Pete Beach, USA 41. Pineda JA, Wang KKW, Hayes R. Biomarkers of proteolytic damage following traumatic brain injury. Brain Pathol 2004;14(2):202- 209. 42. Wu YC, Zhao YB, Lu CZ, Qiao J, Tan YJ. Correlation between serum level of neuron-specific enolase and long-term functional outcome after acute cerebral infarction: prospective study. Hong Kong Med J 2004;10(4):251–254. 43. Wang KK, Ottens AK, Liu MC, Lewis SB, Meegan C, Oli MW, Tortella FC, Hayes RL. Proteomic identification of biomarkers of traumatic brain injury. Expert Rev Proteomics 2005;2(4):603–614. 44. Zhang J, Zhang Y, El-Maaytah M, Ma L, Liu L, Zhou LD. Maxillofacial Injury Severity Score: proposal of a new scoring system. Int J Oral Maxillofac Surg 2006;35(2):109–114. 45. Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64(3):408–414. 46. Chen C, Zhang Y, An JG, He Y, Gong X, Comparative study of four maxillofacial trauma scoring systems and expert score. J Oral Maxillofac Surg 2014;72(11):2212–2220. 47. Sahni V. Maxillofacial Trauma Scoring Systems: A Review. Injury 2016;47(7):1388–1392. 48. Leles JL, Santos EJ, Jorge FD, da Silva ET, Leles CR. Risk factors for maxillofacial injuries in a Brazilian emergency hospital sample. J Appl Oral Sci 2010;18(1):23–29. 49. Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 10.1002/14651858. CD001855, October 25, 1999. 50. Attewel RG, Glase K, McFadden M. Bicycle helmet efﬁcacy: a meta-analysis. Accid Anal Prev 2001;33(3):345–352. 51. Zibung E, Riddez L, Nordenvall C. Helmet use in bicycle trauma patients: a population-based study. Eur J Trauma Emerg Surg 2015;41(5):517–521. 52. Cripton PA, Dressler DM, Stuart CA, Dennison CR, Richards D. Bicycle helmets are highly effective at preventing head injury during head impact: head-form accelerations and injury criteria for helmeted and unhelmeted impacts. Accid Anal Prev 2014;70:1–7. 53. Ergun R, Bostanci U, Akdemir G, Beşkonakli E, Kaptanoğlu E, Gürsoy F, Taşkin Y. Prognostic value of serum neuron-specific enolase after head injury. Neural Res 1998;20(5):418–420. 54. Laterza OF, Modur VR, Crimmins DL, Olander JV, Landt Y, Lee JM, Ladenson JH. Identification of novel brain biomarkers. Clin Chem 2006;52(9):1713–1721.

ͺ 9 10

Chapter 2

Maxillofacial fractures associated with motor vehicle accidents: A review of the current literature

This is an edited version of the manuscript: Muhammad Ruslin, Jan Wolff, Tymour Forouzanfar, Paolo Boffano Maxillofacial fractures associated with motor vehicle accidents: A review of the current literature Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 2015 May;27(3):303–307.

ͳͳ Abstract

Introduction: In many countries, trafﬁc accidents are the most common cause of maxillofacial fractures. Maxillofacial fractures can have various causes, such as trafﬁc accidents, falls, assaults, sports injuries, and others, in isolation or in combination with other injuries. The aim of this article was to review and discuss papers that were published during the past 30 years regarding the distribution and characteristics of motor vehicle accidents-related facial injuries throughout the world.

Methods: We systematically reviewed all papers that were published in English between January 1980 and December 2013 using MEDLINE and the MeSH term “facial fractures” together with the term “motor vehicle”. Fourteen papers in other languages were excluded.

Results: The percentage of motor vehicle accidents as etiological factors in epidemiological studies on maxillofacial injuries ranged between 11% to 85%. On the whole, a progressively decreasing trend was observed, particularly in North America, Brazil, and Europe. A further observed result was the progressive decrease of incidence of facial injuries suffered by pedestrians in the last 30 years. Facial fractures mainly involved the lower third or the middle third in all the considered studies.

Conclusion: Motor vehicle accidents are still one of the most important etiological factors for maxillofacial injuries. A great difference in the incidence of this kind of fractures between developed countries and developing countries can be observed.

ͳʹ Introduction

Maxillofacial fractures can have various causes, such as traffic accidents, falls, assaults, sports injuries, and others, in isolation or in combination with other injuries.1-39 The epidemiology of these fractures varies depending on the geographic area, socioeconomic status, and the period of investigation.1-10 In many countries, traffic accidents are the most common cause of maxillofacial 2 fractures.1-10 Motor vehicle accidents (MVAs) are still among the most frequent causes of facial fractures all over the world, although assault is becoming the most frequent cause in many developed countries.2,40-42 Investigations of MVA-related maxillofacial injuries are crucial to clarify the mechanisms and socioeconomic costs of MVA injuries, in particular because patients with oral and maxillofacial injuries often acquire disabilities and require longterm treatment.1,2,6 In the last 30 years, the implementation of laws that require seat belts and/or airbags in cars and helmets to be worn by motorcyclists has had an impact on the incidence of facial trauma in developed countries.1,2,6,7 Furthermore, socioeconomic reasons such as poor roads and speed limits are a crucial factor that influences the incidence of MVA.6,7 Preventing maxillofacial injuries is a valuable pursuit for improving the quality of life of the involved subjects and decreasing the socioeconomic costs of motor vehicle collision injuries.6-8 Thorough knowledge and understanding of the etiology and epidemiology of MVA-related facial injuries are fundamental for the development of health services, and the adoption of new methods for preventing injuries. The aim of this paper, therefore, was to review and discuss papers that were published during the past 30 years regarding the distribution and characteristics of MVA-related facial injuries throughout the world.

Material and Methods

We systematically reviewed all papers that were published in English between January 1980 and December 2013 using MEDLINE and the MeSH term “facial fractures” together with the term “motor vehicle”. Fourteen papers in other languages were excluded. Papers that presented complete data about the etiology of motor vehicle accidents with appropriate information about car,

ͳ͵ motorcycle and pedestrian accidents were identiﬁed and included. Data were collected on etiology and characteristics of fractures and summarized in Table 2.1. This article was exempt from IRB approval as it is a review of the literature. We followed Helsinki Declaration guidelines.

Results

A total of 27 studies met the inclusion criteria and were included in this review (Tables 2.1 and 2.2). Table 2.1. Etiology of MVA-related maxillofacial fractures: review of epidemiologic studies Number Percentage M:F ratio in Etiology of MVA Country Author Year of patients of MVA (%) MVA victims Car (%) Motorcycle (%) Pedestrian struk by MV (%) Nigeria 1447 72.7 20.9:1 67.2 31.3 6.5 Adekeye Jordan [15] 1980 Jordan 131 61.1 - 50 20 30 Karyouti India [16] 1987 India 262 50 - 41.2 39.7 19.1 Sawhney and Ahuja [17] 1988 Nigeria 442 69.9 3.6:1 68.2 20.8 11.4 Ugboko et al. [18] 1998 The Netherlands 1324 36.6 - 60.2 33.4 6.4 van Beek and Merkx [19 1999 Japan 1502 38.8 - 33.6 59.4 7 Iida et al. [20] 2001 Nigeria 206 35 - 60 25.7 14.3 Olasoji Iran et al. [21] 2002 Iran 237 54 - 57 43 0 Motamedi [22] 2003 Brazil 1024 29.9 - 46.7 40.5 12.8 Brasileiro and Passeri [23] 2006 India 2748 85 4.5:1 73.3 26.7 0 Brasileiro and Passeri [23] 2007 Japan 674 20 - 23.7 65.9 10.4 Sasaki et al. [25] 2009 India 111 74.7 - 74.6 25.4 0 Kamath et al. [26] 2012 India 503 80.3 6.6:1 17 76 3 Kar and Mahavoi [27] 2012 The Netherlands 579 35.2 2.2:1 40 53.3 6.7 Van den Bergh et al. [28] 2012 Greece 727 50.8 5.8:1 36.6 56.1 7.3 Kostakis et al. [29] 2012 Ireland 82 11 2.6:1 94 3 3 Walker et al. [30] 2012 India 740 72 - 5.3 92.1 2.6 Bali et al. [31] 2013 China 1131 46.7 - 66.1 33.9 0 Zhou et al. [32] 2013

RTA: road trafﬁc accidents. Bold character indicate the most frequent category for each author.

Table 2.2. Characteristics of fractures in MVA-related trauma patients: review of epidemiological studies Fractures Author Year Lower third (%) Middle third (%) Upper third (%) Combined (%) 54 32 - 14 Iida et al. [20] 2001 41 56 3 - Buchanan et al. [33 2005 22 70 8 - Erdmann et al. [34] 2008 50 15 4 31 Chalya et al. [35] 2011 41 59 - - Gandhi et al. [36] 2011 72 22 - 6 Mesgarzadeh et al. [37] 2011 50 47 3 - Kostakis et al .[29] 2012 38 48 - 24 Naveen Shankar et al. [38] 2012 69 31 - - Bali et al. [31] 2013 29 63 8 - Mijiti et al. [39] 2014

ͳͶ The percentage of MVA as etiological factors in epidemiological studies on maxillofacial injuries ranged between 11%30 to 85%.24 On the whole, a progressively decreasing trend was observed, particularly in North America, Brazil, and Europe. Data regarding male:female ratio were extremely different too, with results between 2.2:1 and 20.9:1.

The percentages of the categories of MVAs (car, motorcycle and pedestrian) showed a 2 progressive trend all over the world: the incidence of maxillofacial injuries due to car accidents is decreasing, whereas a continuous increase in motorcycle related facial injuries has been observed 2 in Asia (Japan, India) and Europe (The Netherlands, Greece). A further observed result was the progressive decrease of incidence of facial injuries suffered by pedestrians in the last 30 years (Figure 2.1). Facial fractures mainly involved the lower third or the middle third in all the considered studies (Table 2.2 and Figure 2.2).

Figure 2.1. Trends of patients who are victims of motor vehicle accidents-related facial injuries in the last 30 years

Figure 2.2. Characteristics of facial fractures and their involvement of the lower, middle and upper third in the recent literature

ͳͷ

Discussion

Motor vehicle accidents are still one of the most important etiological factors for maxillofacial injuries. Nowadays, their incidence widely varies, as various factors are involved in the prevention of such accidents. In particular, not only road conditions, speed limits, and safety equipment, but also the characteristics of used vehicles, socioeconomic conditions and regulations about alcohol drinking before driving are fundamental for the prevalence of such injuries. In the recent literature, a great difference in the incidence of MVA-related facial fractures between developed countries (20% in Japan, 35.2% in the Netherlands, 11% in Ireland) and developing countries (72–85% in India, 46.7% in China) can be easily observed. Of course, those data cannot be really compared because of the aforementioned differences in regulations and their implementations. The etiology of MVA gives us important information, in particular regarding the progressive decrease of pedestrians suffering from MVA-related injuries. This may be the first result of the establishment and enforcement of more severe laws and regulations with regard to alcohol drinking and speed limits. Unfortunately, there are too many variables to draw any conclusion about car and motorcycle accidents. However, for car accidents, detailed examinations for neck lesions are suggested for the patients involved in MVAs. The decrease of the severity or incidence of head, chest, and abdominal injuries of the vehicle occupants thanks to seat belt use is still controversial, whereas front seat passengers are likely to suffer from less severe head or neck injuries than drivers because of the absence of a steering wheel. Of course, it seems that although wearing a seat belt is effective for preventing fatalities and generally decreasing the severity of injuries to the head or neck and to the trunk, it cannot prevent all oral and maxillofacial injuries in motor vehicle occupants.1 Anyway, some authors confirmed that wearing a seat belt pre-vents the free flight of drivers within the vehicle and contact with the interior of the vehicle (other than the steering wheel).8,9 Furthermore, airbags protect motor vehicle passengers by providing a cushioning barrier between them and the vehicle’s interior hard surfaces, thus making the benefits of an airbag in decreasing drivers’ fatality well recognized.8,9 Occupants of motor vehicles should heed the ubiquitous message that proper seat belt use not only is a highly effective means to reduce the risk of injury in general but also specifically reduces the risk of facial injury.8,9 As for motorcycle accidents, the crucial role of helmets has to be acknowledged. Three types of helmets can be used: fixed full-face, articulated full-face, and open-face. Not only people who do not wear helmets are 3–4 times more likely to sustain a head injury than those who do, but full-face helmets in particular seem to bemostly effective in protecting the face.7,10 Studies on the wearing of helmets by motorcyclists in urban areas have highlighted two main points: the effectiveness of laws aimed at increasing their use and the protection provided against brain injuries and death.7,11

ͳ͸ Legislations making helmet use compulsory for all motorcyclists are crucial to reduce the incidence of facial injuries in this category. As aforementioned in previous articles, it is demonstrated that motorcycle accidents in 100% of the patients cause severe traumatic brain injury, followed by moped/scooter accidents (63.3%). This may be due to the high velocity achieved by motorcycles in conjunction with the inconvenience of wearing helmets, making them more vulnerable in traffic. Instead, car accidents 22 account for only 50% of the patients in the severe traumatic brain injury cases and furthermore for only 16.7% of the patients in the mild cases. This is probably due to compulsory wearing of seat belts and aggressive enforcement of “drinking and driving” laws.12,13 Finally, pedestrians are a peculiar category of patients involved in MVAs. Maxillofacial fractures are not frequently seen in pedestrians injured in motor vehicle accidents. Injuries to the head, shoulder/clavicle, and chest/ribs are observed frequently.1 Most pedestrians patients are children or old persons. This epidemiology may be partly related to the fact that the ability of a pedestrian to avoid a collision with a motor vehicle, or not to be injured seriously even if involved in an accident, is quite different from age to age. The youngest patients may not pay attention to the dangers on the street, whereas older pedestrians might not have high motor ability or reflexes due to the physiological consequences of aging and the presence of systemic pathological conditions.1 In view of the overall cost of care to the society, emphasis should be placed on prevention of road traffic accidents. The public should be adequately informed on the usage of seat belt and helmet, and laws concerning speed limit and alcohol drinking.6 Alcohol initially leads to a reduction in attentiveness, a false perception of velocity, euphoria, and difficulty in spatially discerning different light intensities. At higher concentrations, it determines slow reaction times and sleepiness, a reduction in peripheral vision and poor performance in routine activities, thus making alcohol drinking before driving a serious danger. Therefore, in several countries the penalty for driving under the influence of alcohol has been increased, and drivers who operate motor vehicles with high blood alcohol levels are criminalized.14

Conclusion

Improving our understanding of the mechanisms of facial injuries in motor vehicle accidents can be crucial for the adoption of new methods for preventing injuries, thus decreasing the associated socioeconomic costs of these individuals. However, although fully restrained vehicle occupants are less likely to sustain severe injuries, it may not be possible to entirely prevent maxillofacial injuries. Further, multicentre studies with the assessment of the results of laws enforcement and implementation are needed to clarify their efﬁcacy for maxillofacial injury prevention.

ͳ͹ References

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ͳͺ 29. Kostakis G, Stathopoulos P, Dais P, Gkinis G, Igoumenakis D, Mezitis M, Rallis G. An epidemiologic analysis of 1,142 maxillofacial fractures and concomitant injuries. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114(5 Suppl):S69–S73. 30. Walker TW, Donnellan J, Byrne S, McArdle N, Kerin MJ, McCann PJ. West of Ireland facial injury study. Part 2. Br J Oral Maxillofac Surg 2012;50(7):e99–e103. 31. Bali R, Sharma P, Garg A, Dhillon G.A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India. J Inj Violence Res 2013;5(2):108–116. 32. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Changing pattern in the characteristics of maxillofacial fractures. J Craniofac Surg 2013;24(3):929–933. 33. Buchanan J, Colquhoun A, Friedlander L, Evans S, Whitley B, Thomson M. Maxillofacial fractures at Waikato Hospital, New Zealand: 1989 to 2000. N Z Med J 2005;118(1217):U1529. 2 34. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, Mukundan S, Marcus JR. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60(4):398–403. 2 35. Chalya PL, McHembe M, Mabula JB, Kanumba ES, Gilyoma JM. Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital. J Trauma Manag Outcomes 2011;5(7):1–6. 36. Gandhi S, Ranganathan LK, Solanki M, Mathew GC, Singh I, Bither S. Pattern of maxillofacial fractures at a tertiary hospital in northern India: a 4-year retrospective study of 718 patients. Dent Traumatol 2011;27(4):257–262. 37. Mesgarzadeh AH, Shahamfar M, Azar SF, Shahamfar J. Analysis of the pattern of maxillofacial fractures in north western of Iran: a retrospective study. J Emerg Trauma Shock 2011;4(1):48–52. 38. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R. The pattern of the maxillofacial fractures - A multicentre retrospective study. J Craniomaxillofac Surg 2012;40(8):675–679. 39. Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, Saimaiti A, Morning A. Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: a 5-year retrospective study. J Craniomaxillofac Surg 2014;42(3):227–233. 40. Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, Vesnaver A, Konstantinović VS, Petrović M, Stephens J, Kanzaria A, Bhatti N, Holmes S, Pechalova PF, Bakardjiev AG, Malanchuk VA, Kopchak AV, Galteland P, Mjøen E, Skjelbred P, Grimaud F, Fauvel F, Longis J, Corre P, Løes S, Lekven N, Laverick S, Gordon P, Tamme T, Akermann S, Karagozoglu KH, Kommers SC, Meijer B, Forouzanfar T. European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119(5):499–504. 41. Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, Vesnaver A, Konstantinović VS, Petrović M, Stephens J, Kanzaria A, Bhatti N, Holmes S, Pechalova PF, Bakardjiev AG, Malanchuk VA, Kopchak AV, Galteland P, Mjøen E, Skjelbred P, Bertin H, Marion F, Guiol J, Corre P, Løes S, Lekven N, Laverick S, Gordon P, Tamme T, Akermann S, Karagozoglu KH, Kommers SC, Forouzanfar T. Assault-related maxillofacial injuries: the results from the European Maxillofacial Trauma (EURMAT) multicenter and prospective collaboration. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119(4):385–391. 42. Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, Vesnaver A, Konstantinović VS, Petrović M, Stephens J, Kanzaria A, Bhatti N, Holmes S, Pechalova PF, Bakardjiev AG, Malanchuk VA, Kopchak AV, Galteland P, Mjøen E, Skjelbred P, Koudougou C, Mouallem G, Corre P, Løes S, Lekven N, Laverick S, Gordon P, Tamme T, Akermann S, Karagozoglu KH, Kommers SC, Forouzanfar T. European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study. J Craniomaxillofac Surg 2015;43(1):62–70.

ͳͻ 20

Chapter 3

Motor-vehicle accidents related maxillofacial injuries: A multicenter and

prospective study

This is an edited version of the manuscript: Muhammad Ruslin, Matteo Brucoli, Paolo Boffano, Arnaldo Benech, Jan Wolff, Emil Dediol, Vedran Uglešić, Žiga Kovačič, Aleš Vesnaver, Vitomir S. Konstantinović, Milan Petrović, Jonny Stephens, Amar Kanzaria, Nabeel Bhatti, Simon Holmes, Petia F. Pechalova, Angel G. Bakardjiev, Vladislav A. Malanchuk, Andrey V. Kopchak, Pål Galteland, Even Mjøen, Per Skjelbred, Helios Bertin, F Marion, Julien Guiol, Pierre Corre, Sigbjørn Løes, Njål Lekven, Sean Laverick, Peter Gordon, Tiia Tamme, Stephanie Akermann, K Hakki Karagozoglu, Sofie C. Kommers, Jan G. deVisscher, Tymour Forouzanfar Motor-vehicle accidents related maxillofacial injuries: A multicenter and prospective study. Accepted for Publication

ʹͳ Abstract

Introduction: Facial injuries, including fractures, may have serious long-term implications for victims of motor vehicle accidents (MVA) and important socio economic consequences. Preventing maxillofacial injuries is a valuable pursuit for improving the quality of life of the involved subjects and decreasing the socioeconomic costs of motor vehicle collision injuries. The purpose of this study is to present and discuss the demographics and patterns of MVA-related maxillofacial fractures of a multicenter study.

Methods: This study is based on a systematic computer-assisted database that allowed to prospectively and continuously record all patients hospitalized with maxillofacial fractures in the involved Maxillofacial Surgery Units across Europe, since Monday 31st December 2012 to Sunday 29th December 2013. Therefore, the following data were recorded for each patient: gender, age, etiology, etiology mechanisms, site of facial fractures, Facial Injury Severity Score (FISS), date of injury. For this study, only patients that were admitted to the hospital for MVA related maxillofacial injury were considered.

Results: Of the 3260 patients with maxillofacial fractures admitted within the study period, 326 traumas were due to motor vehicle accidents with a male to female ratio of 2.2:1. The maximum incidence was encountered in Zagreb (Croatia) (18%) and the minimum value was observed in Bergen (Norway) (0%). The most frequent mechanisms were car accidents with 177 cases, followed by motorcycles. The most frequently observed fracture involved the mandible with 199 fractures, followed by maxilla-zygomatic-orbital (MZO) fractures. In all the three groups mandibular and MZO fractures are the two most frequently observed fractures with some variations.

Conclusion: The importance of the perseverance in analyzing MVA related facial injuries with their features and characteristics should be stressed, as they may help to establish prevention strategies and suggestions for all involved countries.

ʹʹ Introduction

Injuries associated with traffic accidents are a problem faced in several countries, and their prevention is often a priority for public health authorities.1-18 In fact, facial injuries, including fractures, may have serious long term implications for victims of motor vehicle accidents (MVA) and important socio economic consequences.1-8 Thus, the knowledge of the factors associated with facial injuries stemming from MVAs is important for the prognosis, the identification of groups at risk, and the establishment of measures to minimize the economic, emotional, psychological, and social impacts of these events.1-8 3

Preventing maxillofacial injuries is a valuable pursuit for improving the quality of life of the involved 3 subjects and decreasing the socioeconomic costs of motor vehicle collision injuries.1-14 Several studies in the literature have described the frequency and severity of facial injuries associated with motor vehicle accidents. However, to our knowledge, no prospective multicentre study about MVA- related maxillofacial injuries has been published. Therefore, several European centers, that had already shown research experience in maxillofacial trauma.15-17 decided to collaborate to start a prospective multicentre study about facial fracture epidemiology in Europe.

The purpose of this study is to present and discuss the demographics and patterns of MVA-related maxillofacial fractures of a European multicenter prospective study about the epidemiology of facial trauma during a year.

Material and Methods

The present study was conducted at several European departments of oral and maxillofacial surgery: the Department of Oral and Maxillofacial Surgery/Pathology at the VU Medical Center and Academic Centre for Dentistry Amsterdam (Amsterdam, The Netherlands), the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia), the Maxilofacial department at the UKC Ljubljana, (Ljubljana, Slovenia), the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia), the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health NHS (London, UK), the Department of maxilla-facial surgery at the Medical University (Plovdiv, Bulgaria), the Department for Oral and Maxillofacial Surgery at the Bogomolets National Medical University (Kiev, Ukraine), the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway), the Service

ʹ͵ de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France), the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway), the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK), and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computer-assisted database that allowed to prospectively and continuously record all patients hospitalized with maxillofacial fractures in the involved Maxillofacial Surgery Units across Europe, since Monday 31st December 2012 to Sunday 29th December 2013. Therefore, the following data were recorded for each patient: gender, age, etiology, etiology mechanisms, site of facial fractures, Facial Injury Severity Scale (FISS), date of injury. For this study, only patients that were admitted to the hospital for MVA-related maxillofacial injury were considered. MVA-related injuries were analyzed and divided according to the type of injury: car accident, motorcycle accidents, pedestrian hitten, unknown/other. Bicycle accidents were excluded. Fractures were determined from a combination of physical examination and imaging (computed tomography scans or conventional radiographs) at admission to hospital and classified in fractures of the mandible, orbito-zygomatic-maxillary complex (OZM), orbit, nose, Le Fort, frontal sinus, and naso-orbital-ethmoidal (NOE) fracture. Orbital fractures were subclassified according to the involved walls and Le Fort fractures were divided according to Le Fort I, II, and III types. Frontal sinus fractures were divided according to the involvement of the anterior and/or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extra- articular condyle, intra-articular condyle. Associated injuries were classified as orthopedic, brain, abdominal, or thoracic. Patient characteristics were analyzed using descriptive statistics. This study was exempt from institutional review board approval as a chart review. We followed Helsinki Declaration guidelines.

Results

Of the 3260 patients with maxillofacial fractures admitted within the study period, 326 traumas were due to motor vehicle accidents. Of course, in the different centers and countries the incidence of MVA-related maxillofacial trauma varied, with the maximum value that was encountered in the Zagreb (Croatia) center study population (39 patients, 18%) and the minimum value that was observed in Bergen (Norway) (0 patients, 0%). On the whole, 225 patients were male and 101 were female, with a male to female ratio of 2.2:1. Mean age was 36.2 years. Alcohol consumption was reported by 59 patients, whereas drugs use was noted in 4 cases.

ʹͶ The most frequent mechanisms of MVA related maxillofacial injury were car accidents with 177 cases, followed by motorcycles (91 patients), pedestrian hitten (33 cases), and other/unknown mechanisms (25 patients). This result was quite uniformly observed in all centers, as showed in Figure 3.1.

Figure 3.1. Percentages of mechanisms of MVA-related maxillofacial injury in the EURMAT centers. (BG, Bulgaria; EST, Estonia; F, France; HR, Croatia; N1, Oslo-Norway; N2, Bergen-Norway; NL, The Netherlands; SLO, Slovenia; SRB, Serbia; UA, Ukraine; UK1, London-England, United Kingdom; UK2, Dundee-Scotland, United Kingdom)

The most frequently observed fracture involved the mandible with 199 fractures, followed by maxilla-zygomatic-orbital (MZO) fractures (136), orbital fractures (36), Le Fort fractures (32), nose fractures (16 fractures), frontal sinus fractures (15), and NOE fractures (8). FISS mean score in the whole study population was 2.39 (range, 1 – 12; median, 2; standard deviation, 1.99). In the “car accident” group mean FISS was 2.54, in the “motorcycle” group the observed mean FISS was 2.47, and in the “pedestrian” group, the mean value of FISS was 1.6. Figure 3.2 shows the differences in fractures distribution according to the three etiological categories.

ʹͷ

Figure 3.2. Fractures distribution according to the three etiological categories

In all the three groups mandibular and MZO fractures are the two most frequently observed fractures with some variations: in the car and motorcycle groups mandibular fractures are the main site of injury, whereas in pedestrian MZO fractures are the most frequently observed fractures. As for associated body injuries, brain and orthopedic lesions are the most frequently observed in all the three groups, as shown by Figure 3.3.

Figure 3.3. Associated body injuries according to the three etiological categories

A peak of traumatic brain injuries has been observed in motorcycle accidents, whereas the peak of orthopedic lesions was encountered in the car study population. Finally, the analysis of the dates of injury showed that the summer months of July and August, as well as November and December, present the highest incidence of MVA related maxillofacial

ʹ͸ injuries (Figure 3.4). The peak of pedestrian injuries was observed in December, whereas the peaks of incidence for car and motorcycle accidents were found in August and November.

3 Figure 3.4. Fractures monthly distribution according to the three etiological categories

Discussion

The analysis of the various patterns of motor vehicle accidents is crucial, although differences in legislations, regulations, socioeconomic conditions, and road features among countries may represent an important bias for any attempt of assessment. For instance, in Europe, every country has its own regulation about speed limit, alcohol and driving policies, and safety equipment, just to mention some variables. For this reason, a multicentre and prospective study to collect epidemiological data regarding MVA-related facial fractures seemed to be the most efficient way to obtain reliable results about this peculiar injury. Of the 3290 patients with maxillofacial fractures admitted within the study period in the different centers, 326 traumas were due to MVAs. Of course, in the different centers and countries the incidence of MVA-related maxillofacial trauma varied, with the maximum value that was encountered in Zagreb. However, in most centers, the percentage of MVAs was about 10%. In comparison with the European literature, this was among the lowest values ever reported. In fact, most recent studies regarding European populations reported percentages ranging between 25% and 60%. This result could confirm the progressive trend of decreasing incidence of MVA maxillofacial injuries in developed countries. On the whole, 225 patients were male and 101 were female, with a male to female ratio of 2.2:1. The slight predominance of males agrees with males/females proportions of European study populations in recent articles. Alcohol consumption was reported by 59 patients, whereas drugs use was noted in 4 cases. Unfortunately, a thorough analysis of alcohol consumption is extremely difficult. Although almost

ʹ͹ 20% of patients’ victims of MVAs referred alcohol consumption, a strict and precise knowledge of quantity, and type of alcohol beverages would be crucial. This kind of analysis would be extremely difficult because several factors should be kept in mind, such as the little collaboration of some patients in speaking about their usual alcohol consumption and the different laws about this topic. The most frequent mechanisms of MVA-related maxillofacial injury were car accidents with 177 cases, followed by motorcycles (91 patients), pedestrian hitten (33 cases), and other/unknown mechanisms (25 patients) (Figure 3.1). This result was quite uniformly observed in all centers, as showed in Figure 3.2. In this article, bicycle accidents were excluded because they were characterized by specific features and populations. The most frequently observed fracture involved the mandible with 199 fractures, followed by MZO fractures (136), orbital fractures (36), Le Fort fractures (32), nose fractures (16 fractures), frontal sinus fractures (15), and NOE fractures (8) (Figure 3.2). FISS mean score in the whole study population was 2.39. In the “car accident” group mean FISS was 2.54, in the “motorcycle” group the observed mean FISS was 2.47, and in the “pedestrian” group, the mean value of FISS was 1.6. Therefore, cars and motorcycles accidents seemed to determine more severe injuries than “pedestrian accidents”. The reason could be the different mechanism of this last type of injury: probably, the most severe impacts to pedestrian may easily determine fatal outcomes, thus causing an underreporting of facial injuries in these patients. Figure 3.2 shows the differences in fractures distribution according to the three etiological categories. In all the three groups mandibular and MZO fractures are the two most frequently observed fractures with just slight variations: in the car and motorcycle groups mandibular fractures are the main site of injury, whereas in pedestrian MZO fractures are the most frequently observed fractures. Of course, further studies about safety equipment (seat belts, airbags, helmet) and their protective effect against MVA-related facial injuries are needed, in spite of the challenge of such enquiry.10-14 As for associated body injuries, traumatic brain and orthopedic lesions are the most frequently observed in all the three groups, as shown by Figure 3.3. A peak of traumatic brain injuries has been observed in motorcycle accidents, whereas the peak of orthopedic lesions was encountered in the car study population. The highest incidence of traumatic brain injuries associated with motorcycle accidents was expected, due to the high velocity achieved by motorcycles in conjunction with the lack of protection in comparison with cars. In spite of the inconvenience of wearing helmets, the compulsory wearing of such protective equipment remains the only defense for such severe injuries.10-14 Finally, the analysis of the dates of injury showed that the summer months of July and August, as well as November and December, present the highest incidence of MVA-related maxillofacial injuries (Figure 3.4). The peak of pedestrian injuries was observed in December, whereas the peaks of incidence for car and motorcycle accidents were found in August and November. This monthly distribution of MVA-related facial injuries confirms the acknowledged trend of maxillofacial

ʹͺ trauma that focuses in summer and winter seasons. In fact, in summer an increased use of vehicles is frequently observed because of school holidays and better weather conditions, whereas in winter months the more critical road conditions may facilitate MVAs because of precipitations.

Conclusion 3 This European multicenter study about MVA-related maxillofacial injury may represent another important stand in our increasing understanding of vehicle accidents and their consequences. The importance of the perseverance in analyzing MVA related facial injuries with their features and 3 characteristics should be stressed, as they may help to establish prevention strategies and suggestions for all involved countries. Further prospective studies about alcohol consumption and driving, as well as about safety equipment could be fundamental to appropriately assess this socially important phenomenon.

ʹͻ

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Surg J 2014;52Craniomaxillofac(10):901– Surg906. 2014;42(8):1717–1722. 15. Boffano P, Kommers SC, Karagozoglu KH, Forouzanfar T. Aetiology of maxillofacial fractures: a review of published studies during 16.15. theGiardaBoffano last 30M,P, years.KommersTavolaccini Br JSC, Oral A, Karagozoglu ArcuriMaxillofac F, Brucoli Surg KH, 2014;52Forouzanfar M, Benech(10):901 T .A. Aetiology– 906.Surgical of approach maxillofacial to isolatedfractures: bilateral a review orbital of published floor fractures. studies during Acta Otorhinolaryngolthe last 30 years. Ital Br 2015;35(5):362J Oral Maxillofac–36 Surg4. 2014;52(10):901–906. 16. Giarda M, Tavolaccini A, Arcuri F, Brucoli M, Benech A. Surgical approach to isolated bilateral orbital floor fractures. Acta 17.16. OtorhinolaryngolBenechGiarda M,A, NicolottiTavolaccini Ital M, 2015;35(5):362 Brucoli A, Arcuri M, Arcuri F,– 36Brucoli 4.F. Intraoral M, Benech extra-mucosal A. 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30 ͵Ͳ ͵Ͳ ͵Ͳ 31 32

Chapter 4

Maxillofacial fractures associated with sport injuries: A review of the current literature

This is an edited version of the manuscript: Paolo Boffano, Muhammad Ruslin, Matteo Brucoli, Arnaldo Benech, Tymour Forouzanfar Maxillofacial fractures associated with sport injuries: A review of the current literature. Submitted

͵͵ Abstract

Introduction: Sport related maxillofacial injuries are progressively increasing, especially in the richest countries. The aim of this paper, therefore, was to review and discuss articles that were published during the past 20 years regarding the distribution and characteristics of sport-related facial injuries throughout the world.

Methods: We systematically reviewed all papers about sport related facial fractures that were published in English between January 2000 and December 2017 using MEDLINE and the MeSH term “facial fractures” together with the term “sport”. Sixteen papers in other languages were excluded.

Results: The percentage of sport as an etiological factor for facial fractures was higher in Europe and Oceania. In sport injuries, males outnumbered females. The most frequent sport was soccer, with some peculiarities due to local diffusion of sports, such as rugby in New Zealand. In most studies the two most frequent sites of injury were the mandible and the zygomatic maxillary complex.

Conclusion: Further multicentre studies with the assessment of preventive measures and long-term observation results are needed to clarify their efficacy for maxillofacial injury prevention.

͵Ͷ Introduction

Maxillofacial fractures can have various causes, such as motor vehicle accidents, aggression, falls, sports injuries, and others. The epidemiology of such fractures varies depending on the geographic area, socioeconomic status, and the period of investigation. Sport related maxillofacial injuries are progressively increasing, especially in the richest countries. Injuries are due to player to- player contact, falls, or direct hits with equipment. Ball sports or sports with projectiles also can be a cause of soft tissue injury. Overall, approximately 11% to 40% of all sports injuries involve the face, and 8% of all facial soft tissue injuries are sports-related. Regardless of sport or country, soft tissue injuries and fractures of the nose, zygoma, and mandible represent the most frequent sites of injury.1 The great variety of sport related facial injuries and the complexity of facial structures makes 4 assessment and treatment of these problems highly important not only for the facial surgeon, but also for the sideline physician. Team physicians should possess an understanding of the most common facial injuries, the anatomy of the face, and the associated management of facial trauma in athletics.1 4 Preventing maxillofacial injuries is a valuable pursuit for improving the quality of life of the involved subjects. Thorough knowledge and understanding of the etiology and epidemiology of sport related facial injuries are fundamental for the development of health services, and the adoption of new methods for preventing injuries. The aim of this paper, therefore, was to review and discuss articles that were published during the past 20 years regarding the distribution and characteristics of sport- related facial injuries throughout the world.

Materials and Methods

We systematically reviewed all papers that were published in English between January 2000 and December 2017 using MEDLINE and the MeSH term “facial fractures” together with the term “sport”. Sixteen papers in other languages were excluded. The percentage of sport injuries in any epidemiological article about maxillofacial trauma since 2000 was recorded and grouped according to continents. Then, only papers that were focused on sport related maxillofacial injuries and that presented complete data about the etiology of different sport accidents with appropriate information about type of injury and sites of fractures were included. Data were collected on etiology and characteristics of fractures and summarized in tables. This article was exempt from IRB approval as it is a review of the literature. We followed Helsinki Declaration guidelines.

͵ͷ Results

The percentages of sport related maxillofacial injuries in worldwide epidemiological studies were recorded and are presented in Table 4.1.

Table 4.1. Percentages of sport related maxillofacial injuries in worldwide epidemiological studies

Continent First Author Year Country N of patients Sport injuries (%) Olasoji 2002 Nigeria 206 4 Adebayo 2003 Nigeria 443 5 Africa Schaftenaar 2009 Tanzania 532 4.9 Chalya 2011 Tanzania 154 2.6 Brasileiro 2006 Brazil 1024 8 America Erdmann 2008 USA 437 11 De Lucena 2016 Brazil 718 7.4 Iida 2001 Japan 1502 9.7 Aksoy 2002 Turkey 553 0.4 Klenk 2003 United Arab Emirates 144 5 Motamedi 2003 Iran 237 6.3 Ansari 2004 Iran 2268 1 Al Ahmed 2004 United Arab Emirates 230 2.6 Erol 2004 Turkey 2901 1.1 Cheema 2006 Pakistan 702 0.5 Kadkhodaie 2006 Iran 7200 0.6 Al-Khateeb 2007 United Arab Emirates 288 3 Subhashraj 2007 India 2748 2 Sasaki 2009 Japan 674 14 Abbas 2009 Pakistan 952 10.9 Ozkaya 2009 Turkey 216 0.9 Lee 2010 Republic of Korea 318 11.9 Venugopal 2010 India 361 3 Asia Gandhi 2011 India 718 0.8 Mesgarzadeh 2011 Iran 170 9.5 Zandi 2011 Iran 895 6.9 Naveen Shankar 2012 India 2027 1 Kapoor 2012 India 1000 1 Kar 2012 India 503 1 Abdullah 2013 Saudi Arabia 200 5.5 Almasri 2013 Saudi Arabia 101 3 Bali 2013 India 740 2 Jin 2013 China 627 1.3 Mijiti 2013 China 1350 3 Zhou 2013 China 1131 1.8 Motamedi 2014 Iran 7369 2.2 Kaul 2014 India 542 0.8 Pandey 2015 India 1108 3.29 Gaddipati 2015 India 1015 1 Kumar 2015 India 2731 1.9 Gassner 2003 Austria 9543 31 Bakardjiev 2007 Bulgaria 1706 1.5 Pombo 2010 Spain 643 11 Walker 2012 Ireland 82 35 Van den Bergh 2012 The Netherlands 579 8.3 Kostakis 2012 Greece 727 3 Europe Kyrgidis 2013 Greece 1239 17.1 Rashid 2013 UK 1261 5 Van Hout 2013 The Netherlands 394 12 Ascani 2014 Italy 306 15.7 Boffano 2015 Europe 3396 11 Schneider 2015 Germany 409 7.1 Buchanan 2005 New Zealand 2527 18 Oceania Cabalag 2013 Australia 980 15 Moore 2015 New Zealand 1975 11.9

The percentage of sport as an etiological factor in epidemiological studies about maxillofacial injuries ranged between 2.6% and 5% in Africa, between 7.4% and 11% in America, between 0.4% and 14% in Asia, between 1.5% and 35% in Europe, and finally between 11.9% and 18% in

͵͸ Oceania. As confirmed by Figure 4.1, trends of sport related facial injuries tend to remain stable in all continents in the last 20 years, particularly in Oceania (that maintains the highest mean percentages of this kind of injuries), America, and Africa.

Figure 4.1. Trends of sport related facial injuries tend to remain stable in all continents in the last 20 years

The percentages of sport injuries in Asian studies seem to be strongly influenced by the great 4 variations of socioeconomic conditions in different countries: in fact, the only results above 10 % were observed in Japan and Korea, whereas most studies reported percentages between 0% and 3%. European results are probably influenced by the high variability of study population even within the same country (for example, Greek articles reported percentages of 3% and 17,1% in just 2 years), although most studies reported percentages above 10%. A total of 8 studies met the inclusion criteria and were included in the most specific part of this review (Table 4.2 and Table 4.3). Data regarding male:female ratio showed a substantial uniformity, with results ranging between 6.5:1 and 13.7:1, with the only exception of the article by Ruslin et al. (3.8:1). On the whole, the most frequent sport was soccer, with some peculiarities due to local diffusion of sports, such as rugby in New Zealand (Table 4.2).

Table 4.2. Etiology of sport-related maxillofacial fractures: review of epidemiologic studies about facial sport injuries

Sport Number First M:F Cricket / Horse Year Country of Soccer Rugby Cycling Skiing Hockey Author ratio Baseball riding patients (%) (%) (%) (%) (%) (%) (%) Maladiere 2001 France 140 7.2:1 25 15 0.7 12.9 7.2 7.9 Exadaktylos 2004 Switzerland 90 6.5:1 13.3 1.1 - 21.1 25.6 8.9 6.7 Morouzis 2005 Greece 125 9:1 64 - - 1.6 3.2 1.6 - Antoun 2008 New Zealand 561 9:1 4.8 52 7.1 - - - - Roccia 2008 Italy 138 8:1 62.3 2.1 - 1.4 14.5 - 6.5 Hwang 2009 South Korea 236 13.7:1 38.1 - 16,1 - 11 - - Murphy 2015 Ireland 162 9:1 22.3 12.4 0.6 3.6 - 3.7 12.4 The Ruslin 2016 108 3.8:1 27.8 8.3 1.9 - - 25 8.3 Netherlands

͵͹ The incidence of facial fractures showed great variations, although in most studies the two most frequent injuries regarded the mandible and the zygomatic maxillary complex with percentages between 20% and 45%. A slightly different result was revealed by the study of by Hwang et al, where nasal fractures represented the 54.2% of fractures (Table 4.3).

Table 4.3. Fractures of sport-related maxillofacial fractures: review of epidemiologic studies

First Number of Fracture type Year Author patients Nose (%) ZMC (%) Orbit (%) Le Fort (%) Mandible (%) Frontal (%) Maladiere 2001 140 15.6 29.9 5.2 5.2 34.4 4.5 Exadaktylos 2004 90 8.3 20.5 18.6 3.8 25.6 5.8 Morouzis 2005 125 6.4 41.6 3.2 1.6 45.9 - Antoun 2008 561 4 29.4 16.9 4.8 41.4 2.3 Roccia 2008 138 5.5 25.9 24 4.9 27.2 1.2 Hwang 2009 236 54.2 6.8 8.9 0.8 16.1 1.3 Murphy 2015 162 12.3 36.4 14 0.6 20 1.2 Ruslin 2016 108 4 45 5 - 32 -

Discussion

Sport accidents are an important etiological factor for maxillofacial injuries, especially in the richest areas of the world. Nowadays, their incidence widely varies, as various factors are involved from the socioeconomic conditions of the study population to the local preference and tradition of the sport, as some contact sports like rugby are naturally more at risk of facial injuries in comparison with others. Then, of course, in some sports the use of prevention devices during practice may also play an important role: for example, the use of mouthguards in rugby, or helmet in ski. As shown in the results section, a great difference in the incidence of sport related facial fractures between developed countries (18% in New Zealand, 35% in Ireland, 31% in Austria, 14% in Japan) and developing countries (0.5% in Pakistan, 0.8% in India, 2.6% in Tanzania) can be easily observed. Of course, as aforementioned the differences between countries and local traditions make it difficult to compare such data. However, it is quite interesting to notice that across the last 20 years the incidence in the respective geographical areas seems to be stable, in contrast with the evolution of motor vehicle accidents (that are decreasing) and aggression and falls related facial injuries (that are increasing). Male to female ratio in sport injuries is uniform with a more or less male predominance. Of course, male numeric preponderance in contact sports such as soccer and rugby seems to be a quite

͵ͺ rational explanation for this result, in addition to the higher number of male athletes in comparison to women. The etiology of sport related maxillofacial injuries give us important information. Soccer is the most frequently responsible sport for maxillofacial fractures. This result is naturally influenced by the wide diffusion of soccer in the considered countries (France, Greece, Italy, South Korea, Ireland, and The Netherlands). In fact, in New Zealand rugby related facial injuries were the most common, whereas in Switzerland skiing and other winter sports were the most frequent causes of facial injuries. Finally, as for fractures type, from the analysis of the considered studies a predominance of mandibular fractures in most articles was observed,57-61 followed by zygomatic fractures.63,64 The only but important exception is represented by the article by Hwang et al. the authors reported an incidence of 54.2% of nasal fractures that overwhelmed the other types of fractures.62 Of course, 4 this can be an important epidemiological issue, as a bias associated with the presence of otolaryngology divisions and maxillofacial divisions within the same hospital is likely and it can be due to the frequent referral of isolated nasal bone fractures to the otolaryngologist. The consequence could be that in the study populations of maxillofacial centers an erroneously low 4 percentage of nasal bone fracture may be recorded. Unfortunately, there are too many variables to draw any conclusion about sport related maxillofacial injuries, as every single sport has different mechanism of injury, diffusion, and preventive devices. However, educational courses for at risk sports players and coaches to promote the use of preventive devices would be extremely important to increase their usage. Sideline doctors, athletes and coaches should also be made aware and educated about most important signs and symptoms of facial fractures to suspect this injury. Nevertheless, although the use of simple preventive devices to prevent facial fractures, such as helmets, and mouth guards, can be implemented, athletes still decide not to wear them, or do not know which is best, or choose a poorly fitting device. Despite the availability of such items, the risk of injury can only be reduced, and is dependent (in addition to the magnitude of force, source, and anatomical site) on the single athlete.

Conclusion Improving our understanding of the mechanisms of facial injuries in sport accidents can be crucial for the adoption of new methods for preventing injuries, thus decreasing the associated socioeconomic costs of these individuals. Further multicentre studies with the assessment of preventive measures and long-term observation results are needed to clarify their efficacy for maxillofacial injury prevention.

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Ͷʹ 43 44

Chapter 5

Sport-Related Maxillofacial Fractures

This is an edited version of the manuscript: Muhammad Ruslin, Paolo Boffano, Y.J.D. ten Brincke, Tymour Forouzanfar, and Henk S. Brand Journal of Craniofacial Surgery 2016 Jan;27(1):e91-e94

Ͷͷ Abstract

Introduction: Sports and exercise are important causes of maxillofacial injuries. Different types of sports might differ in frequency and type of fractures. The aim of the present study was to explore the possible relation between the types of sport practiced and the frequency and nature of the facial bone fractures of patients presenting in an oral and maxillofacial surgery department of a Dutch university center.

Methods: This study is based on an analysis of patient records containing maxillofacial fractures sustained between January 1, 2000 and April 1, 2014 at the Vrije Universiteit University Medical Center (VUmc) in Amsterdam, The Netherlands.

Results: The present study comprised data from 108 patients with 128 maxillofacial fractures. Seventy-nine percent of the patients were male and 21% were female. The patients ranged in age from 10 to 64 years old with a mean age of 30.6 12.0. The highest incidence of sport-related maxillofacial fractures occurred in individuals between the ages of 20 and 29. The most common sport-related fractures were zygoma complex fractures, followed by mandible fractures. Soccer and hockey were the most prominent causes of sport-related maxillofacial trauma in the present study. Coronoid process fractures were only observed in soccer players and not in other sports groups. Mandible angle fractures were relatively more frequent in rugby than in other sports.

Conclucion: Based on the result of this study, we confirm a relation between type of sport and the nature and frequency of the fractures causes and it causes. In addition, our findings are mostly in line with other studies, which suggest that the data might be useful for the development of protocols to prevent maxillofacial trauma in certain sports.

Ͷ͸

Introduction

Major causes of maxillofacial injuries are traffic accidents, falling, and (domestic) violence. Sports and exercise are also important causes of maxillofacial injuries. Sport cause approximately 5% of all mandible fractures and 9% of the fractures in the upper two-thirds of the face. Sport-related accidents are also responsible for approximately 10% of all midfacial.1-4 Elhammali et al.5 found their study of sport-related injuries a significant prevalence of the mid-facial complex (67%) followed by the mandible (29%) and skull base (4%).5 In their review study concerning sports-related maxillofacial trauma, Kunamoto et al.6 suggested that different types of sports differ in frequency and type of fractures. In Italy, soccer is the main cause of maxillofacial trauma, with frequent fractures of the zygomatic bone (44%), the nasal bone (29%), and the mandible (15%). A previous, larger study in Italy also found the same 3 types of fractures most commonly in soccer players, but in different orders: nasal bone fractures (62%), zygomatic bone fractures (15%), and mandible fractures (11%). In a study performed in Brazil, the investigators 5 found that the majority of soccer-related fractures consisted of nasal bone (35%) and orbito- zygomatic complex (35%) followed by mandible (16%) orbital region (13%), frontal bone (2%), and naso-orbito-ethmoid complex (2%).7 When soccer players suffer from mandible fractures, the 5 subcondylar site is most frequently affected (28,6%).8 Horse riders, on the other hand, suffer most frequently from fractures of the zygomatic bone (40%),9 while rugby players suffer most frequently from mandible fractures (65%).10 Several authors stated that geographical differences might also play a role in the frequency and type of sport-related maxillofacial fractures.6,8,11 In Austria, 55.3% of sport-related mandible fractures were caused by skiing,8 and in Switzerland 27% of sport-related maxillofacial fractures were sustained during skiing and snow-boarding.11 On the other hand, a study performed in the United States reported no fractures due to skiing accidents.12 These geographical differences might be affected by different numbers of individuals practicing specific sports. Until now, no data are available on sport-related maxillofacial fractures in the Netherlands. Therefore, the aim of the present study was to explore the possible relation between the types of sport practiced, and the frequency and nature of the facial bone fractures of patients presenting in the oral-maxillofacial department of a Dutch university center.

47 Ͷ͹

Material and Methods

This study is based on an analysis of a patient database from the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Center (VUmc), Amsterdam, The Netherlands. The database consists of retrospectively collected data from January 1, 2000 until January 1, 2010 and systematic computer-assisted databases that have continuously recorded patients with maxillofacial fractures between January 1, 2010 and April 1, 2014. Both surgically and nonsurgically treated patients were included. Only maxillofacial fractures caused by sports were included in this study. The study was performed according to the guidelines of the medical ethical committee of the Free University of Amsterdam. Patients below the age of 4 and above the age of 80 were excluded, as these patients were not expected to participate in community sports. From the medical records, the following data were retrieved: sex, age, type of sports, and type of maxillofacial fracture. Maxillofacial fractures caused by bicycle accidents were considered traffic accidents and were excluded from the study. Fractures caused by skiing, snowboarding, and sled riding were combined into winter sports. Baseball and softball fractures were also combined into softball. The maxillofacial fractures were divided into mandible fractures (angle, body, condyle, guardsman fractures, coronoid process, and symphysis), zygomatic complex fractures, mid-facial fractures (Le Fort 1, 2, and 3, and alveolar process fractures of the maxilla), orbital walls fractures (orbital and sphenoid sinus fractures), nasal bone and frontal sinus fractures, skull fractures (parietal and temporal bone fractures), and multi-trauma (2 or more trauma from different complexes). The IBM SPSS 21 package (IBM, Armonk, NY) was used to analyze associations among multiple variables. Statistical significance was determined using x2, or Fisher exact test, if the sample sizes were too small. P values <0.05 were considered statistically significant.

Results

The study population consisted of 108 patients with 128 maxillofacial fractures (79% male; 21% female). A mean age of 30.6 years (SD, 12.0; range 10 – 64) was observed. The highest incidence of maxillofacial fractures was observed in subjects between 20 and 29 years old (Table 5.1.).

Ͷͺ

Table 5.1. Age distribution of patients with maxillofacial fractures, stratified according to type of sport performed during the accident Count Field Horse Winter Other (Percent Age Soccer Rugby Martial Arts Ice Skating Hockey Riding Sports Sports Within Age Intervals) 10–19 3 (10%) 2 (7%) 5 (56%) 0 (0%) 1 (17%) 0 (0%) 2 (40%) 5 (29%) 18 (17%) 20–29 9 (30%) 17 (63%) 2 (22%) 6 (67%) 1 (17%) 1 (20%) 0 (0%) 3 (18%) 39 (36%) 30–39 10 (33%) 6 (22%) 1 (11%) 1 (11%) 3 (50%) 1 (20%) 2 (40%) 3 (18%) 27 (25%) 40–49 7 (23%) 1 (4%) 0 (0%) 2 (22%) 1 (17%) 1 (20%) 1 (20%) 4 (24%) 17 (16%) 50–59 1 (3%) 1 (4%) 1 (11%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (12%) 5 (5%) 60–69 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (40%) 0 (0%) 0 (0%) 2 (2%) Total 30 (100%) 27 (100%) 9 (100%) 9 (100%) 6 (100%) 5 (100%) 5 (100%) 17 (100%) 108 (100%)

The patients had been engaged in 18 different sports as demonstrated in Table 5.2., where soccer has been the major cause of maxillofacial trauma (28%) followed by field hockey (25%), horse riding (8%), and rugby (8%).

Table 5.2. Frequency distribution of patients with orofacial fractures stratified according to type of sport performed during the accident 5 Type of Sport Number of Patients (Percentage) Soccer 30 (27.8) Field hockey 27 (25.0) Horse riding 9 (8.3) Rugby 9 (8.3) Martial arts 6 (5.6) 5 Ice Skating 5 (4.6) Cricket 2 (1.9) Tennis 1 (0.9) Bicycle racing 1 (0.9) Winter sports, other than ice skating 5 (4.6) Sakeboarding 1 (0.9) Inline skating 3 (2.8) Ice hockey 1 (0.9) Skydiving 1 (0.9) Softball 3 (2.8) Gymnastics 1 (0.9) Go-karting 3 (2.8)

The most commonly sports observed related maxillofacial fractures were zygomatic complex fractures (45%), followed by mandible fractures (32%) (Table 5.3.). Table 5.3. Maxillofacial fractures, stratified according to type of sport performed during the accident Winter Field Horse Martial Ice Sports, Other Fracture Soccer Rugby Total Hockey Riding arts Skating Other Than Sports Ice Skating Mandible 8 (27%) 10 (37%) 3 (33%) 2 (22%) 3 (50%) 0 (0%) 1 (20%) 7 (41%) 34 (32%) Zygoma complex 14 (47%) 13 (48%) 4 (44%) 5 (56%) 1 (17%) 4 (80%) 2 (40%) 6 (35%) 49 (45%) Midface 0 (0%) 0 (0%) 1 (11%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (1%) Orbital wall 1 (3%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) 2 (40%) 1 (6%) 5 (5%) Nasal bone / frontal sinus 1 (3%) 1 (4%) 0 (0%) 2 (22%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 4 (4%) Multiple 6 (20%) 3 (11%) 1 (11%) 0 (0%) 1 (17%) 1 (20%) 0 (0%) 3 (18%) 15 (14%) Total 30 (100%) 27 (100%) 9 (100%) 9 (100%) 6 (100%) 5 (100%) 5 (100%) 17 (100%) 108 (100%)

Ͷͻ Further, no significant differences were observed between the sport categories. Soccer had the highest percentage of multitrauma (20%) followed by field hockey (11%). Looking only at the mandible fractures, the mandible body was mostly affected (45%), followed by mandible condyle (36%) (Table 5.4.). Sports soccer and rugby were solely played by males (Figure 5.1.).

Table 5.4. Location of mandible fracture, stratified according to type of sport performed during the accident Winter Field Horse Martial Ice Sports, Other Location Soccer Rugby Total Hockey Riding Arts Skating other than Sports Ice Skating Angle 0 (0%) 1 (8%) 0 (0%) 2 (67%) 1 (17%) 0 (0%) 0 (0%) 1 (8%) 5 (9%) Body 7 (47%) 8 (62%) 1 (25%) 1 (33%) 2 (33%) 0 (0%) 1 (100%) 5 (38%) 25 (45%) Condyle 5 (33%) 4 (31%) 2 (50%) 0 (0%) 2 (33%) 0 (0%) 0 (0%) 7 (54%) 20 (36%) Coronoid process 3 (20%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (5%) Guardsman 0 (0%) 0 (0%) 1 (25%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (2%) Symphysis 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) 1 (2%) Total 15 (100%) 13 (100%) 4 (100%) 3 (100%) 6 (100%) 0 (0%) 1 (100%) 13 (100%) 39 (100%)

Figure 5.1. Some sports, such as soccer and rugby, were solely played by males

Discussion

This study confirms previous studies that sport is a major cause of maxillofacial injuries. The most common sport-related fractures were zygomatic complex fractures, followed by mandible fractures, which is in accordance with results from previous studies.9-11,13,14

ͷͲ Nasal bone fractures were nearly absent in the present data, since these fractures are usually treated by the ear nose throat (ENT) department and therefore not included in the database used. The highest incidence of sport-related maxillofacial fractures occurred in individuals between the ages of 20 and 29 (Table 5.1.). Other studies found similar results, although the 36% in the present study is slightly lower than the 41.4% to 52.9% in previous studies.4,5,8,10,13,14 Most sport-related fractures occurred in males, which is also in accordance with previous studies.7-10,13,14 Soccer and hockey were the most prominent causes of sport-related maxillofacial trauma in the present study. This is in line with the large number of people playing soccer in the Netherlands. Hockey, on the other hand, is only the ninth most popular sport in the Netherlands (Centraal Bureau Statistiek; CBS).15,16 However, field hockey participation in the Amsterdam and the adjacent Amstelveen suburb is high, with 6.5% of all Dutch hockey players playing in this area (CBS). We suspect that this may contribute to the prominence of hockey-related trauma in our data. However, this high number could also be a result of hockey being a high-risk sport for maxillofacial trauma. In Ireland,17 gaelic football was the sport responsible for most fractures followed by cricket and soccer, respectively, while in Japan10 and Great Britain18 rugby proved to be the main cause. In Switzerland11 most fractures were sustained during skiing and snow- 5 boarding during team sports such as soccer or ice hockey and cycling. In Brazil, nasal fractures were the most common soccer-related facial fractures. In a retrospectively performed review about 5 451 Germans soccer players who had suffered injuries during soccer games, the head was affected in 23.9% of cases. The areas most frequently involved were the facial and occipital regions.19 An interesting observation of the present study is that coronoid process fractures were only observed in soccer players and not in other sports groups. This might be due to the fact that the most common cause of accident in soccer is impact against another player.10 However, in the study of Emshoff et al.8 no fractures in the coronoid region were observed among 28 fractures related to soccer. Mandible angle fractures were more seen in rugby than in other sports. Other studies also demonstrated that the mandible is often a site of injury in rugby,9,10 but these previous studies did not specify the frequency of mandible angle fractures in rugby players. Other authors reported the most frequent fracture site of the mandible was the angle followed by the symphysis in maxillofacial fractures sustained during sports played with ball.20 The present study has several potential limitations. In the first place, it is a single-center study. Amsterdam has 3 other hospitals where patients with maxillofacial injuries are treated. As the patients are not equally divided into the 4 hospitals in Amsterdam, some hospitals may see more and different kinds of patients than the other hospitals. Therefore, the results in the present study might not be fully representative for the Netherlands. As the data were partly collected retrospectively, this may also have introduced information bias.

ͷͳ Conclusion

In conclusion, the results of this study suggest a relation between type of sport and the nature and frequency of the fractures it causes. Furthermore, we confirm a relation between type of sport and the nature and frequency of the fractures causes and it causes. Our findings are mostly in line with other studies, which suggest that the data might be useful for the development of protocols to prevent maxillofacial trauma in certain sports.

ͷʹ References

1. Van den Bergh B, van Es C, Forouzanfar T. Analysis of mandibular fractures. J Craniofac Surg 2011;22(5):1631–1634. 2. Van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40(6):e165–e169. 3. Salentijn EG, Van den Bergh B, Forouzanfar T. A ten-year analysis of midfacial fractures. J Craniomaxillofac Surg 2013;41(7):630– 636. 4. Gassner R, Bosh R, Tuli T, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries: implication for prevention. Oral Surg Oral Med Oral Pathol Radiol Endod 1999;87(1):27–33. 5. Elhammali N, Bremerich A, Rustemeyer J. Demographical and clinical aspects of sports-related maxillofacial and skull base fractures in hospitalised patients. Int J Oral Maxillofac Surg 2010;39(9):857–862. 6. Kunamoto DP, Maeda Y. A literature review of sports-related maxillofacial trauma. Gen Dent 2004;52(3):270–280. 7. Goldenberg DC, Dini GM, Pereira MD, Gurgel A, Bastos EO, Nagarkar P, Gemperli R, Ferreira LM. Soccer-related facial trauma: multicenter experience in 2 Brazilian University Hospitals. Plast Reconstr Surg Glob Open 2014;2(6):e168. 8. Emshoff R, Scho¨ ning H, Ro¨ thler G, Waldhart E. Trends in the incidence and cause of sport-related mandibular fractures: a retrospective analysis. J Oral Maxillofac Surg 1997;55(6):585–592. 9. Frenguelli A, Ruscito P, Bicciolo G, Rizzo S, Massarelli M. Head and neck trauma in sporting activities. Review of 208 cases. J Craniomaxillofac Surg 1991;19(4):178–181. 10. Tanaka N, Hayashi S, Amagasa T, Kohama G. Maxillofacial fractures sustained during sports. J Oral Maxillofac Surg 1996;54(6): 715–719. 11. Exadaktylos AK, Eggensperger NM, Eggali S, Smolka KM, Zimmermann H, Lizuka T. Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland. Br J Sports Med 2004;38:750–753. 5 12. Soporowski NJ, Tesini DA, Weiss AI. Survey of ofacial sports-related injuries. J Mass Dent Soc 1994;43(4):16–20. 13. Cerulli G, Carboni A, Mercurio A, Perugini M, Becelli R. Soccer-related craniomaxillofacial injuries. J Craniofac Surg 2002;13(5): 627–630. 14. Mourouzis C, Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg 5 2005;34(6):635–638. 15. Centraal Bureau Statistiek. Available at: http://www.cbs.nl. Accessed June 25, 2014 16. Koninklijke Nederlandse Hockey Bond. Available at: http://www.knhb.nl. Accessed June 25, 2014 17. Fasola AO, Obiechina AE, Arotiba JT. Sports related maxillofacial fractures in 77 Nigerian patients. Afr J Med Med Sci 2000;29(3- 4):215–217. 18. Hill CM, Burford K, Martin A, Thomas DW. A one-year review of maxillofacial sports injuries treated at an accident and emergency department. Br J Oral Maxillofac Surg 1998;36(1):44–47. 19. Kolodziej MA, Koblitz S, Nimsky C, Hellwig D. Mechanisms and consequences of head injuries in soccer: a study of 451 patients. Neurosurg Focus 2011;31(5):E1 20. Delilbasi C, Yamazawa M, Nomura K, Lida S, Kogo M. Maxillofacial fractures sustained during sports played with a ball. Oral Surg Oral Med Oral Pathol Radiol Endod 2004;97(1):23–27.

ͷ͵ 54

Chapter 6

Sport related maxillofacial fractures: A multicenter and prospective study

This is an edited version of the manuscript: Muhammad Ruslin, Matteo Brucoli, Paolo Boffano, Arnaldo Benech, Emil Dediol, Vedran Uglešić, Žiga Kovačič, Aleš Vesnaver, Vitomir S. Konstantinović, Milan Petrović, Jonny Stephens, Amar Kanzaria, Nabeel Bhatti, Simon Holmes, Petia F. Pechalova, Angel G. Bakardjiev, Vladislav A. Malanchuk, Andrey V. Kopchak, Pål Galteland, Even Mjøen, Per Skjelbred, Helios Bertin, Pierre Corre, Sigbjørn Løes, Njål Lekven, Sean Laverick, Peter Gordon, Tiia Tamme, Stephanie Akermann, K Hakki Karagozoglu, Sofie C. Kommers, Jan G. de Visscher, Tymour Forouzanfar Sport related maxillofacial fractures: A multicenter and prospective study Submitted

ͷͷ Abstract

Introduction: The purpose of this study is to present and discuss the demographics and patterns of sport–related maxillofacial fractures of a multicenter study.

Results: The 3260 patients with maxillofacial fractures admitted within the study period, 275 traumas were due to sport accidents with a male to female ratio of 4.1:1. Soccer was most frequently responsible for maxillofacial injuries (33%), followed by rugby (18%) and skiing (12%). The most frequently observed fracture involved the mandible with 116 fractures, followed by maxilla-zygomatic-orbital (MZO) fractures.

Conclusion: There are still too many variables to draw any conclusion about sport-related maxillofacial injuries, as every single sport has different mechanism of injury, diffusion, and preventive devices.

ͷ͸ Introduction

Injuries associated with sport accidents are a problem faced in several countries, and their prevention is often a priority for public health authorities. Sport related maxillofacial injuries are progressively increasing, especially in the richest countries.1-52 Injuries are due to player to-player contact, falls, or direct hits with equipment. In fact, facial injuries, including fractures, may have serious long-term implications for victims of sport accidents and important socio economic consequences.1-8 The great variety of sport related facial injuries and the complexity of facial structures makes assessment and treatment of these problems highly important not only for the facial surgeon, but also for the sideline physician. Thus, the knowledge of the factors associated with facial injuries stemming from sport accidents is important for the prognosis, the identification of groups at risk, and the establishment of measures to minimize the economic, emotional, psychological, and social impacts of these events.1-8 Preventing maxillofacial injuries is a valuable pursuit for improving the quality of life of the involved subjects.1-14 Several studies in the literature have described the frequency and severity of facial injuries associated with sport accidents. However, to our knowledge, no prospective multicentre study about sport-related maxillofacial injuries has been published. Therefore, several European centers, that had already shown research experience in maxillofacial trauma,1-16 decided to collaborate to start a prospective multicentre study about facial fracture epidemiology in Europe. 6 The purpose of this study is to present and discuss the demographics and patterns of sport related maxillofacial fractures of a European multicenter prospective study about the epidemiology of facial trauma during a year.

Material and Methods

The present study was conducted at several European departments of oral and maxillofacial surgery: the Department of Oral and Maxillofacial Surgery/Pathology at the VU Medical Center and Academic Center for Dentistry Amsterdam (Amsterdam, The Netherlands), the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia), the Maxilofacial department at the UKC Ljubljana, (Ljubljana, Slovenia), the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia), the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health NHS (London, UK), the Department of maxilla-facial surgery at the Medical University (Plovdiv, Bulgaria), the Department for Oral and Maxillo-facial Surgery at the Bogomolets National Medical University (Kiev, Ukraine), the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway), the Service

ͷ͹ de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France), the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway), the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK), and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computer-assisted database that allowed to prospectively and continuously record all patients hospitalized with maxillofacial fractures in the involved Maxillofacial Surgery Units across Europe, since Monday 31st December 2012 to Sunday 29th December 2013. Therefore, the following data were recorded for each patient: gender, age, etiology (type of sport), site of facial fractures, Facial Injury Severity Scale (FISS), date of injury. For this study, only patients that were admitted to the hospital for sport related maxillofacial injury were considered. Sport-related injuries were analyzed and divided according to the type of sport. Fractures were determined from a combination of physical examination and imaging (computed tomography scans or conventional radiographs) at admission to hospital and classified in fractures of the mandible, orbito-zygomatic-maxillary complex (OZM), orbit, nose, Le Fort, frontal sinus, and naso-orbital- ethmoidal (NOE) fracture. Orbital fractures were subclassified according to the involved walls and Le Fort fractures were divided according to Le Fort I, II, and III types. Frontal sinus fractures were divided according to the involvement of the anterior and/or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extra-articular condyle, intra- articular condyle. Associated injuries were classified as orthopedic, brain, abdominal, or thoracic. Patient characteristics were analyzed using descriptive statistics. This study obtained institutional review board approval from the leading center. We followed Helsinki Declaration guidelines.

Results

Of the 3260 patients with maxillofacial fractures admitted within the study period, 275 traumas (8.4%) were due to sport accidents. On the whole, 222 patients were male and 53 were female, with a male to female ratio of 4.1:1. Mean age was 27.6 years (median, 24; range, 3 – 66; standard deviation, 14.1). The most numerous decade of age was the first (10 – 19 years) with 87 patients (31.6%), followed by the second decade (20 – 29 years) that included 76 patients (27.6%), and the third (51 patients, 18.5%) (Figure 6.1).

ͷͺ

Figure 6.1. Decades of age of patients affected by sport-related maxillofacial injury in the study population

As for the male to female ratio according to decades of age, Figure 6.2 shows that percentages of men and women were similar at all ages with a remarkable predominance of males, ranging between 5.9:1 (2nd decade) and 2.5:1 (4th decade). 6

Figure 6.2. Male and female distribution according to decades of age in the study population

As for etiology, soccer was most frequently responsible for maxillofacial injuries (33%), followed by rugby (18%), skiing (12%), basketball (5%), hockey (4.5%), and combat sports (2.5%); the remaining cases were from unspecified or other sports (Figure 6.3).

ͷͻ

Figure 6.3. Distribution of patients according to the types of sport cause of injury

On the whole, 329 fractures were found. The most frequently observed fracture involved the mandible with 116 fractures, followed by maxilla-zygomatic-orbital (MZO) fractures (82), orbital fractures (54), nose fractures (40 fractures), and Le Fort fractures (18) (Figure 6.4). Among mandibular fractures, a quite uniform distribution was observed with 34 condylar fractures, 28 angle fractures, 26 body fractures, and 25 parasymphyseal/symphyseal fractures.

Figure 6.4. Fractures distribution within the study population

͸Ͳ FISS mean score in the whole study population was 1.8 (range, 1 – 6; median, 1; standard deviation, 1.22). Associated body injuries were observed in few patients (18 patients) that mainly suffered from brain (14 patients) and orthopedic lesions (6 patients). A peak of traumatic brain injuries and orthopedic injuries was observed in rugby and skiing accidents. Finally, the analysis of the dates of injury showed a quite uniform distribution, with the final months of the year from September to December presenting the highest incidence of sport related maxillofacial injuries (Figure 6.5).

Figure 6.5. Fractures monthly distribution

Discussion

The analysis of the various patterns of sport related accidents is crucial, although differences in socioeconomic conditions and traditions among countries may represent an important bias for any attempt of assessment. The incidence of sport related facial fractures widely varies, also because some contact sports like rugby are naturally more at risk of facial injuries in comparison with others. Then, of course, in some sports the use of prevention devices during practice may also play an important role: for example, the use of mouthguards in rugby, or helmet in ski. In our study population, an incidence of

͸ͳ about 8.4% was found, that appeared to be quite low in comparison with recent articles from developed countries (18% in New Zealand, 35% in Ireland, 31% in Austria), but higher than developing countries (0.5% in Pakistan, 0.8% in India, 2.6% in Tanzania). The male to female ratio observed in our study population of 4.1:1 confirmed the expected male predominance, due to the male numeric preponderance in contact sports such as soccer and rugby and to the higher number of male athletes in comparison to women. Furthermore, no surprise derived from the age of the considered patients, as about 59% of the study population age was between 10 and 29 years. The etiology of sport related maxillofacial injuries give us important information. In our study, soccer was the most frequently responsible sport for maxillofacial fractures, although this result is naturally influenced by the wide diffusion of soccer in the some of the considered countries (France, The Netherlands, United Kingdom). As expected, rugby and skiing were important etiological factors too. The most frequently observed fracture involved the mandible with 116 fractures, followed by maxilla-zygomatic-orbital (MZO) fractures (82), orbital fractures (54), nose fractures (40 fractures), and Le Fort fractures (18) (Figure 6.4). Among mandibular fractures, a curiously quite uniform distribution was observed between condylar, angle fractures, body fractures, and parasymphyseal/ symphyseal fractures. An important epidemiological issue can be represented by nose fractures, as the presence of otolaryngology divisions and maxillofacial divisions within the same hospital may determine the frequent referral of isolated nasal bone fractures to the otolaryngologist, and thus the exclusion from the present study. The consequence could be that in the study populations of maxillofacial centers an erroneously low percentage of nasal bone fracture may be recorded. The low FISS mean score in the whole study population of 1.8 and the rarity of associated body injuries (18 patients) seem to suggest that the habitual character of sport related facial injury is a “puntiform” trauma, with the involvement of a single bone in most cases. Skiing may represent the most frequent exception, which more often causes polytrauma because of the high speed and energy trauma. Finally, the analysis of the dates of injury curiously showed a highest incidence of sport related maxillofacial injuries during the final months of the year, with no apparent explanation. Unfortunately, there are still too many variables to draw any conclusion about sport related maxillofacial injuries, as every single sport has different mechanism of injury, diffusion, and preventive devices. However, educational courses for at risk sports players and coaches to promote the use of preventive devices would be extremely important to increase their usage. Despite the availability of such items, the risk of injury can only be reduced, and is dependent (in addition to the magnitude of force, source, and anatomical site) on the single athlete.

͸ʹ Conclusion

This European multicenter study about sport related maxillofacial injury might represent another important stand in our increasing understanding of the epidemiology of sport accidents and their consequences. The importance of the perseverance in analyzing sport related facial injuries with their features and characteristics should be stressed, as they may help to establish prevention strategies and suggestions for all involved countries.

͸͵ References

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Etiology and injury patterns of maxillofacial fractures from the years 2010 to 2013 in Mecklenburg-Western Pomerania, Germany: A retrospective study of 409 patients. J Craniomaxillofac Surg 2015;43(10):1948–51. 53. Buchanan J, Colquhoun A, Friedlander L, Evans S, Whitley B, Thomson M. Maxillofacial fractures at Waikato Hospital, New Zealand: 1989 to 2000. N Z Med J 2005;118(1217):U1529. 54. Cabalag MS, Wasiak J, Andrew NE, Tang J, Kirby JC, Morgan DJ. Epidemiology and management of maxillofacial fractures in an Australian trauma centre. J Plast Reconstr Aesthet Surg 2014;67(2):183–189. 55. Moore BK, Smit R, Colquhoun A, Thompson WM. Maxillofacial fractures at Waikato Hospital, New Zealand: 2004 to 2013. N Z Med J 2015;128(1426):96–102. 56. Maladière E, Bado F, Meningaud JP, Guilbert F, Bertrand JC. Aetiology and incidence of facial fractures sustained during sports: a prospective study of 140 patients. Int J Oral Maxillofac Surg 2001;30(4):291–295.

͸ͷ 57. Exadaktylos AK, Eggensperger NM, Eggli S, Smolka KM, Zimmermann H, Iizuka T. Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland. Br J Sports Med 2004;38(6):750–753. 58. Mourouzis C, Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg 2005;34(6):635–638. 59. Antoun JS, Lee KH. Sports-related maxillofacial fractures over an 11-year period. J Oral Maxillofac Surg 2008;66(3):504–508. 60. Roccia F, Diaspro A, Nasi A, Berrone S. Management of sport-related maxillofacial injuries. J Craniofac Surg 2008;19(2):377–382. 61. Hwang K, You SH, Lee HS. Outcome analysis of sports-related multiple facial fractures. J Craniofac Surg 2009;20(3):825–829. 62. Murphy C, O'Connell JE, Kearns G, Stassen L. Sports-Related Maxillofacial Injuries. J Craniofac Surg 2015;26(7):2120–2123. 63. Ruslin M, Boffano P, ten Brincke YJ, Forouzanfar T, Brand HS. Sport-Related Maxillo-Facial Fractures. J Craniofac Surg 2016; 27(1):e91–e94. 64. Roccia F, Caldarelli C, Spada MC, Brucoli M, Beatrice F, Ruffino S, Benech A, Ramieri G, Berrone S. Development of a regional database for studying epidemiology of maxillofacial trauma. J Craniofac Surg 2010;21(4):1045–1050. 65. Leinhart J, Toldi J, Tennison M. Facial Trauma in Sports. Curr Sports Med Rep 2017;16(1):23–29. 66. Salentijn EG, Peerdeman SM, Boffano P, van den Berg B, Forouzanfar T. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 2014;42(6):705–170. 67. Salentijn EG, Collin JD, Boffano P, Forouzanfar T. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: Complications and treatment. J Craniomaxillofac Surg 2014;42(8):1717–1722. 68. Boffano P, Kommers SC, Karagozoglu KH, Forouzanfar T. Aetiology of maxillofacial fractures: a review of published studies during the last 30 years. Br J Oral Maxillofac Surg 2014;52(10):901–906. 69. Giarda M, Tavolaccini A, Arcuri F, Brucoli M, Benech A. Surgical approach to isolated bilateral orbital floor fractures. Acta Otorhinolaryngol Ital 2015;35(5):362–364. 70. Benech A, Nicolotti M, Brucoli M, Arcuri F. Intraoral extra-mucosal fixation of fractures in the atrophic edentulous mandible. Int J Oral Maxillofac Surg 2013;42(4):460–463. 71. Arcuri F, Brucoli M, Baragiotta N, Benech R, Ferrero S, Benech A. Analysis of complications following endoscopically assisted treatment of mandibular condylar fractures. J Craniofac Surg 2012;23(3):e196–e198. 72. Brucoli M, Arcuri F, Cavenaghi R, Benech A. Analysis of complications after surgical repair of orbital fractures. J Craniofac Surg 2011;22(4):1387–1390

͸͸ 67 68

Chapter 7

Dental trauma in association with maxillofacial fractures: An epidemiological study

This is an edited version of the manuscript: Muhammad Ruslin, Jan Wolff, Henk S. Brand, Paolo Boffano, Tymour Forouzanfar Dental trauma in association with maxillofacial fractures: An epidemiological study Dental Traumatology 2015; August;31(4):318-323

͸ͻ Abstract

Introduction: Dental injury and facial soft tissue are one of the most commonly seen injuries in patients with maxillofacial trauma. The prevalence of dental injury is highly worldwide and mostly occurs in childhood and adolescence. The aim of this study was to retrospectively investigate the incidence and associated factors of dental trauma in patients with maxillofacial fractures at the VU Medical Center in Amsterdam.

Methods: Data from 707 patients who were treated surgically for maxillofacial fractures were evaluated. The data were collected retrospectively from patient files and other available databases. The data collected included date of fracture, age, gender, type of fracture, and injured teeth.

Results: Of the total 707 patients, 164 patients (23.2%) presented dental injuries associated with facial fractures. Mandibular condylar fractures, mandibular parasymphyseal fractures, Le Fort fractures, and mandibular body fractures were found to be significantly more associated with dental injury. Zygomatic arch or zygomatic complex fractures were significantly less associated with dental injury. Women had a significant higher risk of facial fractures with dental injuries than men. The maxilla demonstrated the highest incidence of injured teeth. The most affected teeth were the maxillary incisors (33.1%), followed by mandible incisors (13.6%), mandible molars (12.8%), and maxillary premolars (12.6%).

Conclusion: Our findings show a higher risk of dental injury among patients with a mandibular condylar fracture and mandibular parasymphyseal fracture but a lower risk of dental injury among patients with a zygomatic arch or zygomatic complex fracture. On average, patients had more than three injured teeth, with most of the injured teeth being in the upper jaw. The maxillary incisors, followed by the mandible incisors, were the most injured teeth.

͹Ͳ Introduction

When a maxillofacial trauma occurs, the most common types of injuries are facial soft tissue injury and dental injury. The prevalence of dental injury is highly worldwide and mostly occurs in childhood and adolescence.1-6 Andreasen et al.1,7 found injuries to permanent anterior teeth in one in four adults and in one in five children. The prevalence of dental injury varies considerably between countries,2-6 and it is determined by many factors such as behavioral and cultural diversity, social and economic status, the age of the population that is investigated, and the lack of standardization in dental trauma research. Depending on the severity of the accident, fractures to facial bones may also occur. Trauma resulting in only maxillofacial fractures has been frequently studied.8-15 Findings show the age group most susceptible to only facial fractures is 19–30 years,9,10,12,14,15 although some researchers have reported that the 20–40 years age group is the most susceptible.11-13 Dental injury that is associated with other maxillofacial trauma is also commonly seen. At the time of writing, seven articles have been published in several countries that describe the frequency and type of dental injury associated with maxillofacial fractures.2,12-17 These studies have shown that the prevalence of dental injuries in patients with facial bone fractures ranges from 13% up to 23%.2,12,13,16,17 Exceptions to these findings are the research of Zhou et al.14 and da Silva et al.15 These researchers found the prevalence of patients with dental injuries in combination with facial fractures to be 41.8% and 2.1%, respectively. Many of the patients studied were aged between 20 and 30 years.14,16 Dental trauma may influence the treatment of facial fractures and usually requires postoperative 7 dental treatment, which in turn requires good communication with the treating dentist. Furthermore, facial fractures can also have an influence on the treatment of dental injuries. In some cases, 7 dental treatment is not possible after fracture reduction due to facial swelling and can lead to subsequent premature tooth loss in some cases. In the Netherlands, maxillofacial surgeons commonly perform first aid dental treatment. This makes it important to understand the prevalence of dental trauma in relation to facial fractures. A previous study performed in the Netherlands by van den Bergh et al.9 investigated the incidence and etiology of maxillofacial trauma. They found zygomatic and mandibular bone fractures to be the most common bone fracture in both men and women. Together, these fractures account for approximately 80% of all facial fractures. A study that investigates the relationship between dental injuries and facial fractures in the Netherlands has yet to be performed. The aim of this present study was therefore to retrospectively investigate the incidence and associated factors of dental trauma in patients with maxillofacial fractures at the VU University Medical Center, Amsterdam, from January 2000 until March 2013.

͹ͳ Material and methods

This study is based on an analysis of a patient database from the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Center (VUmc), Amsterdam, the Netherlands. The patient database comprised retrospectively collected data from January 1, 2000, until January 1, 2010, and a systematic computerassisted database that has continuously recorded patients with maxillofacial fractures between January 1, 2010, and March 1, 2013. The study was performed according to the guidelines of the Medical Ethics Committee of the Free University of Amsterdam. Only surgically treated patients were included in the study. Totally edentulous patients, patients with a nose fracture or fractures in the dentoalveolar complex, and patients who received no surgical treatment were excluded from the study. The patient data included date of fracture, age, gender, type of fracture, and site of injured teeth. In the study, patients were divided into three groups based on their age at the time of trauma: children (0–12 years), teenagers (13–19 years), and adults (20 years and older). Adult patients were further categorized into the age groups: 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80 years and older. The facial fractures were subdivided into fractures of the frontal sinus, orbital fractures, fractures of the zygoma complex, zygomatic arch fractures, Le Fort I/II/III fractures, mandibular coronoid fractures, condylar fractures, mandibular ramus fractures, mandibular angulus fractures, mandibular body fractures, and parasymphyseal fractures. All of these fractures were registered on the left side, the right side, or on both sides. The site of the injured teeth was classified as maxillary or mandibular and then further subdivided in incisors, canines, premolars, and molars. The type of dental injury was not further specified. Statistical analysis was performed using SPSS (version 18.0) to assess the relationship between dental injury and other relevant variables. The data were analyzed using the chi-squared test, the independent-sample t-test, and the one-sample t-test, and P-values of 0.005 or less were considered to be statistically significant.

Results

In total, 707 patients with facial fractures were included in the study. Table 7.1. shows the descriptive statistics. The study population comprised 525 males and 182 females, giving a male- to-female ratio of 2.9:1. The mean age of the patients was 33.6 years, with a range from 2 to 88 years. The majority of patients (233 patients, 33.0%) with facial fractures were aged 20 to 29 years. No significant difference between males and females was found (chi-squared test). Of these

͹ʹ patients, 164 patients (23.2%) presented dental injuries associated with facial fractures. Of these, 106 were male and 58 female, giving a male-to-female ratio of 1.8:1. Their mean age was 31.4 years, ranging from 5 to 69 years. Most of the patients (55 patients, 33.5%) with associated dental injury were aged 20–29 years (Table 7.1). Furthermore, results showed women had a significant higher risk of facial fractures with dental injuries than men (chi-squared, P = 0.001), and men had a significant higher risk of only facial fractures than women (P = 0.001).

Table 7.1. Descriptive statistic Total patient group Patients with only dental injuries Age (years) Gender Gender Male (%) Female (%) Total (%) Male (%) Female (%) Total (%) 0-9 3 (0.6) 3 (1.6) 6 (0.8) 0 - 1 (1.7) 1 (0.6) 10-19 73 (13.9) 22 (12.1) 95 (13.4) 22 (20.8) 10 (17.2) 32 (19.5) 20-29 182 (34.7) 51 (28) 233 (33) 37 (35) 18 (31) 55 (33.5) 30-39 118 (22.5) 37 (20.3) 155 (21.9) 24 (22.6) 14 (24.1) 38 (23.2) 40-49 88 (16.8) 33 (18.1) 121 (17.1) 11 (10.4) 9 (15.5) 20 (12.2) 50-59 38 (7.2) 17 (9.3) 55 (7.8) 8 (7.5) 3 (5.2) 11 (6.7) 60-69 17 (3.2) 12 (6.6) 29 (4.1) 4 (3.8) 3 (5.2) 7 (4.3) 70-79 4 (0.8) 6 (3.3) 10 (1.4) 0 - 0 - 0 - 80-89 2 (0.4) 1 (0.5) 3 (0.4) 0 - 0 - 0 - Total 525 (100) 182 (100) 707 (100) 106 (100) 58 (100) 164 (100)

Among the total group, 1231 maxillofacial bone fractures were recorded, which accounts for a mean of 1.74 fractures per patient. The mean for patients with dental injury associated with fractures proved to be higher (mean 2.48; P < 0.05). Table 7.2. shows that the zygomatic complex is the most fractured bone (25.35%), followed by the mandibular condyle (22.7%). In contrast to this finding, the lower third of the face was more susceptible to fractures than the upper two-thirds. Looking at the group with facial fractures and dental injuries, the mandibular condylus proved to be 7 most fractured bone (38.7%), followed by fractures of the mandibular parasymphyseal region (22.4%). No dental injury was found with the zygomatic arch fractures. In this group, the lower third 7 of the face was also more susceptible to fractures than the upper two-thirds of the face. Statistical analysis showed that dental injury occurred significantly more frequently in association with mandibular condylar fracture (P < 0.001), mandibular parasymphyseal fracture (P < 0.001), Le Fort fracture (P < 0.001), and mandibular body fracture (P = 0.049) (Table 7.2). There is a significantly lower risk for dental injury in association with injury in the zygomatic region (P < 0.001).

͹͵ Table 7.2. Facial fractures and presence of dental injury Dental injuries Site No (%) Yes (%) Total (%) Frontal sinus 34 (4.1) 13 (3.2) 47 (3.8) Orbital 30 (3.6) 12 (3.0) 42 (3.4) Upper 2/3 Le Fort 56 (6.8) 51** (12.6) 107 (8.7) Zygomatic complex 287** (34.8) 24 (5.9) 311 (25.3) Zygomatic arch 39** (4.7) 0 (0.0) 39 (3.2) Total upper 2/3 446 (54.1) 100 (24.6) 546 (44.4) Mandibular condylar 122 (14.8) 157** (3.2) 279 (22.7) Coronoid process 8 (1.0) 5 (3.0) 13 (1.1) Mandibular ramus 4 (0.5) 1 (12.6) 5 (0.4) Lower 1/3 Mandibular angle 76 (9.2) 20 (5.9) 96 (7.8) Mandibular body 80 (9.7) 32** (0.0) 112 (9.1) Mandibular parasymphysis 89 (10.8) 91** (24.6) 180 (14.6) Total lower 1/3 397 (45.9) 306 (24.6) 685 (55.6) Total 825 (100.0) 406 (100.0) 1231 (100.0)

*Chi-squared test, P < 0.05; **Chi-squared test, P < 0.001.

A total of 508 injured teeth were observed (averaged 3.55 teeth per patient). Table 7.3. shows the numbers and distribution of the injured teeth. The maxilla had the most injured teeth (308 teeth). The teeth most affected were the maxillary incisors with 168 teeth (33.1%), followed by 69 mandible incisors (13.6%), 65 mandible molars (12.8%), and 64 maxillary premolars (12.6%).

Table 7.3. Distribution of the injured teeth Dental injuries Total Maxila Incisor 168 Canine 21 Premolar 64 Molar 55 Total maxila 308 Mandible Incisor 69 Canine 20 Premolar 46 Molar 65 Total mandible 200 Total 508

As seen in Table 7.4., the major cause of facial fractures accompanied by dental injury was traffic accidents followed by falls and violence. Furthermore, in the dental injury group, it was observed that the incidence of sport as a cause of injury was significantly lower when compared with the total population.

͹Ͷ Table 7.4. Etiologi of maxillofacial fractures Patients with maxillofacial fractures (%) Patients with maxillofacial fractures and dental injuries (%) Fail 128 (18.1) 43* (26.2) Traffic accident pedestrian 16 (2.3) 2 (1.2) Traffic accident bicycle 159 (22.5) 64* (39.0) Traffic accident TMMW 90 (12.7) 20 (12.2) Traffic accident CAR 34 (4.8) 7 (4.3) Sport 83 (11.7) 5* (3.0) Violence 173 (24.5) 20* (12.2) Work 7 (1.0) 1 (0.6) Other 17 (2.4) 2 (1.2) Total 707 (100) 164 (100)

*Significance, P < 0.001

Dicussion

Our study evaluated all patients presenting with facial trauma accompanied with dental injury at the VU University Medical Center (VUmc) in Amsterdam, the Netherlands, over a period of 13 years. VU University Medical Center is a University Hospital and one of the main hospitals that treats facial injuries in the greater Amsterdam area. Patients who did not receive surgical treatment were excluded from the study. In this study, we found a prevalence of dental injury in association with facial fractures of 23.2%. Iso-Kungas et al.17 found a similar prevalence of 22.5%, although their population comprised only pediatric patients. Our prevalence of dental injury in association with 7 facial fractures was higher than the prevalence found by Lieger et al.13 with 19.5%, Thoren et al.12 7 with 16%, Gassner et al.18 with 18.9%, Roccia et al.16 with 13.1%, but lower than the prevalence found by Zhou et al.14 (41.8%). The relatively high prevalence of dental injury in our study can partly be explained by our inclusion criteria. We were mainly interested in patients who had received surgical treatment for their maxillofacial injury. Therefore, patients treated nonsurgically had probably suffered less severe trauma without any associated dental injury. In our total study population, most of the patients were aged between 20 and 29 years. This is in agreement with the majority of the recent studies that have investigated facial fractures.8-12,14,15 Lieger et al.13 found that most patients were between 31 and 40 years old. However, their study group also contained totally edentulous patients. Of the 164 patients with facial fractures and dental injury, most were between 20 and 29 years old. This finding is in line with other recent studies on maxillofacial fractures.14,16,18 The prevalence of isolated dental injury varies considerably,1 but tends to occur most frequently in children and adolescents.1,2,4,5,18 Iso-Kungas et al.17 investigated a group of pediatric patients and found higher figures than were found in other studies that focused on adults. They concluded that dental injury together with facial fractures was generally more complicated in children than in adults.17

͹ͷ As in other studies, we found a male predominance in both the total group and the group with dental injury with facial fractures.8,12-18 This is a similar finding to studies that investigated dental injury only. Many of these studies found a male-to-female ratio of 2:1.4,9,21 However, in our study we found that women had a statistically higher association for dental injuries with facial fractures compared with their male counterparts. Roccia et al.16 found the same association. However, Thoren et al.12 worked in the same field and found no significant association between gender and incidence of dental injury. In this present study, the bone most susceptible to fracture was the zygomatic complex, followed by the mandibular condylar. Thoren et al.12 reported slightly different results, with mandibular fractures being the most prevalent, followed by zygomatico-orbital fractures. In the group with facial fractures and dental injury, the mandibular condyle was the most fractured bone, followed by the mandibular parasymphyseal region. This corresponds to the findings of Roccia et al.16 who reported the same results. Furthermore, we found that the lower third of the face was more susceptible to fractures than the upper two-thirds of the face in both the group with dental injury and the group without dental injury. This contrasts with the findings of other researchers who found that most fractures occurred in the upper two-thirds of the face in the group without dental injury.12,15,16 However, in accordance with the findings of our survey, most studies have reported the lower third of the face to be more susceptible to fractures in the group with facial fractures and dental injury.12,15-17 One explanation for the higher incidence of facial fractures in the lower third of the face found in our study could be that most patients in the Amsterdam area are treated for bicycle accidents and not for interpersonal violence. As a result, those patients treated for bicycle accidents at the VUMC have a higher susceptibility to fractures in the lower third of the face. Our results showed that the mandibular condylar fracture, mandibular parasymphyseal fracture, Le Fort fracture, and mandibular body fracture were significantly more associated with dental injury. Lieger et al.13 found that patients with dental injury had a higher risk of symphysis fractures, followed by condylar fractures. Zhou et al.14 also found significantly more dental injury with only symphysis fractures. Other authors reported that dental injury was significantly more associated with mandibular fractures.12,16,17 However, da Silva et al.15 observed more maxillary fractures than mandibular fractures with dental injury, although this conclusion was based on only seven patients with facial fractures combined with dental injury. The results of the present study show a mean of 3.55 injured teeth per patient. This is higher than the findings of Thoren et al.12 who found a mean of 2.5 injured teeth, Iso-Kungas et al.17 who found a mean of 3.2 injured teeth, and Roccia et al.16 who found a mean of 2.8 injured teeth per patient. Zhou et al.14 found a higher mean number of injured teeth per patient (4.68 teeth), but they also reported a higher number of patients with dental injuries than in our study. The maxilla contained the most injured teeth in our patient group. Other studies have reported similar results:12-14,16 one study found a similar number of injured teeth in the upper and lower jaw.17 Similar to other studies,2-14,16,17 our study found maxillary incisors to be the teeth most effected, followed by the

͹͸ mandibular incisors. This corresponds with the findings of studies that investigated isolated dental mandibular incisors. This corresponds with the findings of studies that investigated isolated dental injuries, where most of the injured teeth were in the anterior segment.4,7,19-22 injuries, where most of the injured teeth were in the anterior segment.4,7,19-22 Several studies22-26 have reported a temporal shift in the importance of different causes of facial Several studies22-26 have reported a temporal shift in the importance of different causes of facial bone fractures. In particular, the role of traffic accidents as a cause of facial bone fracture has bone fractures. In particular, the role of traffic accidents as a cause of facial bone fracture has decreased, whereas the number of facial bone fractures caused by violence and sport injuries has decreased, whereas the number of facial bone fractures caused by violence and sport injuries has increased. However, in our study, we found injuries caused by two-wheeled motor vehicle (TWMV) increased. However, in our study, we found injuries caused by two-wheeled motor vehicle (TWMV) accidents have increased significantly and sport-related accidents have significantly decreased. accidents have increased significantly and sport-related accidents have significantly decreased. Although we did not find a significant difference, we also observed a slight and slow increase in the Although we did not find a significant difference, we also observed a slight and slow increase in the number of fractures caused by violence over the study period. When we examined the causes of number of fractures caused by violence over the study period. When we examined the causes of maxillofacial fractures with associated dental injuries, we found a similar trend for violence as an maxillofacial fractures with associated dental injuries, we found a similar trend for violence as an increasing cause. increasing cause. The present study had several potential limitations. In the first place, it was a single-center study. The present study had several potential limitations. In the first place, it was a single-center study. There are three other hospitals in Amsterdam where patients with maxillofacial injuries are treated. There are three other hospitals in Amsterdam where patients with maxillofacial injuries are treated. As the patients are not divided equally among the four hospitals in Amsterdam, some hospitals As the patients are not divided equally among the four hospitals in Amsterdam, some hospitals may see more and different kinds of patients than other hospitals. Therefore, the results in the may see more and different kinds of patients than other hospitals. Therefore, the results in the present study might not be fully representative for the Netherlands. As the data were partly present study might not be fully representative for the Netherlands. As the data were partly collected retrospectively, this may also introduce information bias. Nevertheless, the results found collected retrospectively, this may also introduce information bias. Nevertheless, the results found in this study are mostly in line with other studies and suggest that the data might be useful for the in this study are mostly in line with other studies and suggest that the data might be useful for the development of protocols to prevent maxillofacial trauma accompanied with or without dental injury. development of protocols to prevent maxillofacial trauma accompanied with or without dental injury. Because oral and maxillofacial injuries are associated with functional, socioeconomic, and Because oral and maxillofacial injuries are associated with functional, socioeconomic, and psychological factors, it is important to take appropriate preventative measures. Prevention can be psychological factors, it is important to take appropriate preventative measures. Prevention can be accomplished with various safety measures such as seatbelts, airbags, stricter speed limits, road accomplished with various safety measures such as seatbelts, airbags, stricter speed limits, road safety training, using different lanes for different types of vehicles, tougher drunk driving laws, and 7 safety training, using different lanes for different types of vehicles, tougher drunk driving laws, and 7 the use of protective sport equipment such as helmets, mouth guards, and face shields.23,25,27–29 In 7 the use of protective sport equipment such as helmets, mouth guards, and face shields.23,25,27–29 In the Netherlands, very few people wear helmets while cycling. Although helmets provide significant the Netherlands, very few people wear helmets while cycling. Although helmets provide significant protection against brain injury,28,30 they are less useful against facial fractures of the mandible protection against brain injury,28,30 they are less useful against facial fractures of the mandible because the chin area is not protected. because the chin area is not protected.

Conclusion Conclusion

The results of this study showed that men had the most fractured bones, but women had a The results of this study showed that men had the most fractured bones, but women had a significantly higher risk of facial fractures with dental injury. We found a higher risk of dental injury significantly higher risk of facial fractures with dental injury. We found a higher risk of dental injury among patients with a mandibular condylar fracture, mandibular parasymphyseal fracture, Le Fort among patients with a mandibular condylar fracture, mandibular parasymphyseal fracture, Le Fort fracture, or mandibular body fracture and a lower risk among patients with zygomatic arch or fracture, or mandibular body fracture and a lower risk among patients with zygomatic arch or zygomatic complex fractures. On average, patients had more than three injured teeth, with most of zygomatic complex fractures. On average, patients had more than three injured teeth, with most of

͹͹ ͹͹ the injured teeth being in the upper jaw. The maxillary incisors, followed by the mandibular incisors, were the most injured teeth. Traffic accidents were found to be the major cause of dental injuries. Further, research on various safety measures and on the treatment and survival of injured teeth to improve patient treatment strategy is recommended.

͹ͺ References 1. Glendor U, Marcenes W, Andreasen JO. Classification, epidemiology and etiology. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. Oxford, UK: Bleckwell Publishing; 2007. p. 217–54. 2. Gassner R, Bosch R, Tuli R, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries. Implication for prevention. Oral Surg Oral Med Oral Pathol Ral Radiol Endod 1999;87(1):27–33. 3. Andreasen JO. Etiology and pathogenesis of traumatic dentalinjuries. A clinical studie of 1,298 cases. Scand J Dent Res 1970;78(4): 329–342. 4. Glendor U, halling A, Andersson L, Elier-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the country of Vastmanland, Sweden. Swed Dent J 1996;20(1-2):15–28. 5. Glendor U. Epidemiology of traumatic dental injuries-a12 year review of the literature. Dent Traumatol 2008;24(6):603–611. 6. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45(1):2–9. 7. Kastle LM, Gift HC, Bhat M, Swango PA. Prevalence of incisor trauma in persons 6-50 years of age: United States, 1988–1991. J Dent Res 1996;75:696–705. 8. Naveen Shankar A, Naveen Shankar V, Hedge N, Sharma, Prasad R. The pattern of the maxillofacial fractures - A multicenter retrospective study. J Craniomaxillofac Surg 2012;40(8):675–679. 9. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40(6):e165–e169. 10. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(2):166–170. 11. Bali R, Sharma P, Garg A, Dhillon G. A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India. J Inj Violence Res 2013;5(2):108–116. 12. Thoren H, Numminen L, Snall J, Kormi E, Lindqvist C, Lizuka T, Tornwall J. Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg 2010;39(8):774–778. 13. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg 2009;67(8):1680–1684. 14. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with maxillofacial fractures. Dental Traumatol 2013;29(4): 285–290. 15. da Silva AC, Passeri LA, Mazzonetto R, De Moraes M, Moreira RW. Incidence of dental trauma associated with facial trauma in Brazil: a 1-year evaluation. Dent Traumatol 2004;20(1):6–11. 16. Roccia F, Boffano P, Bianchi FA, Ramieri G. An 11-year review of dental injuries associated with maxillofacial fractures in Turin, Italy. J Oral Maxillofac Surg 2013;17(4):269–274. 17. Iso-Kungas P, Tornwall J, Suominen AL, Lindqvist C, Thoren H. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofacial Surg 2012;70(2):396–400. 18. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Craniomaxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J 7 Craniomaxillofac Surg 2003;31(1):51–61. 19. Lauridsen E, Hermann NV, Gerds TA, Kreiborg S, Andreasen JO. Pattern of traumatic dental injuries in the permanent dentition 7 among children, adolescents, and adults. Dent Traumatol 2012;28(5):358–363. 20. Caldas AD, Burgos MEA. A retrospective study of traumatic dental injuries in Brazilian dental trauma clinic. Dent Traumatol 2001;17(6):250–253. 21. Rajab LD. Trumatic dental injuries in children presenting for treatment at the Department of Pediatric Dentistry, Faculty of Dentistry, University of Jordan, 1997–2000. Dent Traumatol 2003;19(1):6–11. 22. Borssen E, Holm AK. Traumatic dental injuries in a cohort of 16-years-olds in Northern Sweden. Endod Dent Traumatol 1997;13(6): 276–280. 23. Fasola AO, Nyako EA, Obiechina AE, Arotiba JT. Trends inthe characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg 2003;61(10):1140–1143. 24. Kyrgidis A, Koloutsos G, Kommata A, Lazarides N, Antoniades K. Incidence, aetiology, treatment outcome and complications of maxillofacial fractures. A retrospective study from Northern Greece. J Craniomaxillofac Surg 2013;41(7):637–643. 25. van Beck GJ, Merkx CA. Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral Maxillofac Surg 1999;28(6):424– 428. 26. Kostakis G, Stathopoulus P, Dais P, Gkinis G, Igoumenakis D, Mezitis M, Rallis G. An epidemiologic analysis of 1142 maxillofacial fractures and concomitant injuries. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114(5 Suppl):S69–S73. 27. Exadaktylos AK, Eggensperger NM, Eggli S, Smolka KM, Zimmermann H, Iizuka T. Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland. Br J Sports Med 2004;38(6):750–753. 28. Thompson DC, Nunn ME, Thompson RS, Rivara FP. Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA 1996;276(24):1974–1975. 29. McMullin BT, Rhee JS, Pintar FA, Szabo A, Yoganandan N. Facial fractures in motor vehicle collisions. Arch Facial Plast Surg 2009;11(3):165–170. 30. Lee JH, Cho BK, Park WJ. A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg 2010;38(3):192– 196.

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Chapter 8

The Maxillofacial Injury Severity Score (MFISS) and Facial Injury Severity Scale (FISS) as a predictor brain injury with maxillofacial fractures patients

This is an edited version of the manuscript: Muhammad Ruslin, Paolo Boffano, HCW de Vet, M Brucoli, KH Karagozoglu, Tymour Forouzanfar The Maxillofacial Injury Severity Score (MFISS) and Facial Injury Severity Scale (FISS) as a predictor brain injury with maxillofacial fractures patients Submitted

ͺͳ Abstract

Introduction: The aims of this study were to assess prognostic value of Maxillofacial Injury Severity Score (MFISS) and Facial Injury Severity Scale (FISS) in detecting brain injury and maxillofacial fractures patients at the VU Medical Center in Amsterdam.

Methods: The data were collected retrospectively from patient files and other available databases. The data collected included age, gender, cause of trauma, and diagnosis of moderate to severe traumatic brain injury (TBI). Two commonly used systems were selected: MFISS and FISS, each patient was graded according to these two systems. Results of the two scoring systems score were compared, and statistical analysis was performed to assess association between brain injury and age, etiology and trauma score values.

Results: Of the total 1326 patients, 52 patients were diagnosed with TBI. Both FISS and MFISS proved to be associated significantly with TBI. Higher FISS and MFISS were associated with a higher TBI cases. The sensitivity and specificity analyses demonstrated that the best values were for the FISS 3 and 5, and for the MFISS 7. Other parameters such as age, gender, location of the facture ets, did not improve the results.

Conclusion: FISS and MFISS proven to be useful and valuable assessment tools for diagnosing TBI. However, the clinician can choose the cut-off point with the best sensitivity and specificity fitting in the depending on the hospital policy. Combinations with other patient specific parameters did not improve the results.

ͺʹ Introduction

The most common types of injuries after maxillofacial injuries are facial soft tissue injury, and depending on the severity of the accident, fractures to facial bones may also occur. Trauma resulting in only maxillofacial fractures has been frequently studied.1-4 The facial skeleton comprises the bone of the maxilla, zygoma, and the bony walls of the nasal cavity, paranasal sinuses, and orbit and the mandible. It is one of the most complex arrangements of curving bony structures in the body and it is commonly involved in brain injury.5 Maxillofacial trauma with associated traumatic brain injury (TBI) carries significant potential for mortality and neurological morbidity.6,7 TBI is defined as loss of consciousness and/or post- traumatic amnesia in a patient with a non-penetrating head injury.8 The association between maxillofacial trauma and brain injury is still a matter of current debate. Numerous studies on maxillofacial trauma accompanies with traumatic brain injury have been carried out.9-14 According to Davidoff et al.8 facial fractures proven to be strongly associated with traumatic brain injury.8 On the other hand, Haug et al.15 found a 76% incidence of neurologic injury associated with facial fractures. Furthermore, Haug et al.15 stressed that, in case of a trauma to the midface, energy will be directly transmitted to the cranium, causing damage to the brain.15 In contrast to these studies, many authors have the opinion that no association exists between maxillofacial trauma and brain injury. In their study Lee et al.16 demonstrated that facial fractures are not associated with an increased risk of traumatic brain injury, theorizing that facial bones act as a protective cushion for the brain.16 This is in line with the study performed by Chang et al.17 who stated that the maxilla and the surrounding midfacial bones act as an absorption barrier against high impact energy caused by trauma, thus protecting the brain from damage. Due to these mechanisms fewer brain injuries are expected to occur. Knowing the consequences of untreated brain injury, it is very important to detect in early stage the brain injuries accompanied the maxillofacial fractures. 8 In the literature several severity indices for maxillofacial trauma are noted.18-21 Two most used classification scores are and Facial Injury Severity Scale (FISS)19 and the Maxillofacial Injury Severity Score (MFISS).18,20 Both systems combine the Injury Severity Score parameters of maxillofacial function and appearance (e.g., limited opening of mouth, malocclusion, facial deformity). Furthermore, they are based on the Abbreviated Injury Scale (AIS).18-20 The FISS includes the classification of laceration of facial soft tissue as well as that of bone. However, the classification of bones is not very detailed. Therefore, it cannot be used to distinguish displaced and comminuted fractures.19,20 Scoring systems such as the MFISS are useful to classify not only anatomic damages, but also the impairment of maxillofacial function and facial appearance, subsequently reflecting the effect of maxillofacial injury on quality of life. The use of trauma score and severity grade in trauma studies can provide the basis to decide the most appropriate treatment strategy, and to predict the survival probability of injured patients and

ͺ͵ the impact on health status in the future.18 To our knowledge there is lack of information in the literature concerning the association of FISS and MFISS with TBI. The aim of the present study was twofold. First, to investigate the correlation between FISS, and MFISS with TBI. Second, to study the sensitivity and specificity of these classifications in detecting brain injury in patients with maxillofacial fractures. In doing so the authors wanted to investigate the clinical use of these tests.

Materials and Methods

This study is based on an analysis of a patient database from the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Center (VUmc), Amsterdam, the Netherlands. The patient database comprised retrospectively collected data from January 1, 2002, until January 1, 2010, and a systematic computer-assisted database that has continuously recorded patients with maxillofacial fractures between January 1, 2010, and April 1, 2013. The study was performed according to the guidelines of the Medical Ethics Committee of the Free University of Amsterdam. Surgically and non-surgically treated maxillofacial trauma patients with and without TBI were included in the study. Totally edentulous patients, patients with a nose fracture or dentoalveolar fractures were excluded. The patient data included date of fracture, age, gender, type of fracture, and diagnosis of moderate/severe traumatic brain injury. The facial fractures were subdivided into fractures of the frontal sinus, orbital fractures, fractures of the zygoma complex, zygomatic arch fractures, Le Fort I/II/III fractures, mandibular coronoid fractures, condylar fractures, mandibular ramus fractures, mandibular angulus fractures, mandibular body fractures, and parasymphyseal fractures. All of these fractures were registered on the left side, the right side, or on both sides. The FISS and MFISS were calculated for each patient. Statistical analysis was performed using SPSS (version 18.0) to assess the relationship between brain injury and FISS and MFISS. We used 2 X 2 tables to calculate the sensitivity and specificity values for different cut-off points of FISS and MFISS in showing brain injury (Table 8.1). The best cut-off point was selected by 2 authors (T.F. and R.d.V) and was defined as one with best balance of sensitivity and specificity. Further, data were analyzed using logistic regression analysis, chi-squared test, the independent- sample t-test, and the one-sample t-test, and p-values of 0.05 or less were considered to be statistically significant.

ͺͶ Table 8.1. Calculation of sensitivity and specificity

Cut-off MFISS of FISS NO brain injury Brain injury ≥ Cut-off A B < Cut-off C D Sensitivity, a/(a+c); Specificity, d/(b+d)

Results

On the whole, between 2002 and 2013, 1326 patients affected by maxillofacial fractures were referred and treated at the Department of Oral and Maxillofacial Surgery at the VUmc. The mean age of patients whom suffered from maxillofacial injuries was 39.2 years (range 5 – 98, SD 19.64). Most patients were grouped in the 2nd decade (20–29 years) with 351 cases, followed by the 3rd (30 – 39 years) and the 4th (40 – 49 years). Most patients were males (68.25%). The etiology of the maxillofacial injuries was mostly from fall (24.5%), followed by traffic bicycle accidents (20.14%) and assaults (18.29 %). Out of 1326 patients of the study population, 52 subjects (4%) were diagnosed with a moderate to severe TBI. A motor vehicle accident was the main etiological factor in patients who presented with traumatic brain injury, with 22 patients with TBI out of 52 (42,3%). A statistically significant association was observed between motor vehicle accidents (MVA) related maxillofacial injuries and the diagnosis of TBI (p < 0.05). In fact, among the various mechanisms of injury, patients who had MVAs were most likely to have moderate to severe traumatic brain injuries, whereas age did not seem to represent a particular risk factor for TBI. According to decades of age, a quite uniform distribution of traumatic brain injury was observed 88 with no statistically significant differences. FISS mean value was found to be 2.25 (range, 1 – 21; SD, 1.93), with the most frequent observed values being 1 (55%), followed by 4 (15%), and 3 (11%). MFISS mean calculated value was 5.70 (range, 1 – 48; SD, 3.90), with the most frequent observed values of 6 (57%), 3 (20%), and 2 (10%). FISS seemed to statistically associated with TBI (p < 0.00005, IC95% 9.7 – 31.9, OR 17.6), but risk of neurotrauma only increased with FISS > or = 5. The value of MFISS was statistically associated with the diagnosis of TBI too (p < 0.00005, IC95% 3.9 – 12.6, OR 7). With this score system, risk of neurotrauma only increased with MFISS > or = 7. In Table 8.2a., and 8.2b., the calculated sensitivity and specificity of FISS and MFISS according to different cut-off points are demonstrated. The best results were seen in the FISS with the cut-off point of 3 and 5. For MFISS the best cut-off point proved to be 7. The cross-tabs for the two best points of the FISS are shown in Table 8.3a and 8.3b as an example.

ͺͷ

Table 8.2a. Shows the calculated sensitivity and specificity at various cu-off points for the FISS 1 3 5 7 Sens. 100 75 53.8 28.8 Speci. 0.5 67.8 93.7 97.6

Table 8.2b. Shows the calculated sensitivity and specificity at various cut-off points for the MFISS. 1 3 7 10 Sens. 100 90.4 42.3 21.2 Speci. 0.6 10.9 90.6 96.7

Using 5 as cut-off point we found 28 patients with neurotrauma in 108 patients with a FISS of 5 or higher. This is 53.8% of all patients with neurotrauma (Table 8.3a.).

Table 8.3a. Shows the cross-tab for the calculation of sensitivity and specificity for the FISS cut-off point 5 Neurotrauma Total No Yes Count 1194 24 1218 < 5 % within neurotrauma 93.7 46.2 91.9 Count 80 28 108 ≥ 5 % within neurotrauma 6.3 53.8 8.1 Count 1274 52 1326 Total % within neurotrauma 100.0 100.0 100.0

Whereas 24 patients of 1218 patients with a FISS lower than 5 had neurotrauma (46.2% of all neurotrauma patients). A FISS of 3 or higher includes 75% of the neurotrauma patients. However, the group of patients in this cut-off point consisted of 450 patients. 876 patients had a FISS score lower than 3.25% of these patients proved to have neurotrauma (Table 8.3b.).

Table 8.3b. Shows the cross-tab for the calculation of sensitivity and specificity for the FISS cut-off point 3 Neurotrauma Total No Yes Count 863 13 876 <3 % within neurotrauma 67.7 25.0 66.1

Count 411 39 450 ≥3 % within neurotrauma 32.3 75.0 33.9 Count 1274 52 1326 Total % within neurotrauma 100.0 100.0 100.0

Combinations of MFISS and FISS with other parameters including age, gender, location of the fracture and cause of the trauma did not improve the results. The location of the fracture site was divided in “2/3 upper part of the face” and the “1/3 lower part of the face”. Further to investigate the role of MVA in TBI we divided the cause of trauma in “MVA” and “non-MVA”. Both location and MVA separately did not show conclusive results concerning sensitivity and specificity (these results are not shown).

ͺ͸ Discussion

Early recognition of associated TBIs is a fundamental part of initial assessment and treatment planning in facial trauma patients and could significantly reduce morbidity and mortality associated with these life threatening injuries.22 There may be important risks to the patient if the diagnosis of minor head injury is missed. In fact, symptoms such as impaired memory and concentration and persistent headaches can become chronic and limit function and safe return to work. Finally, if the severity of concussion is not diagnosed, then patients may be given inadequate advice regarding follow-up and return to sports or work.23 According to a recent study based on finite element analysis of maxillofacial trauma associated with TBIs, site and direction of facial impact played a key role in determining the severity and location of the facial bone fracture, which in turns influenced those of the traumatic brain injury.22 This study confirmed that severity of brain injury is highly associated with the proximity of location of impact to the brain: in particular, owing to its close proximity to the brain, the anterior-inferior frontal lobe experiences injuries with higher severity.22 Previous studies demonstrated that the presence of facial bone fractures is actually a marker for increased risk of brain injury, observing that patients with facial fracture had a greater chance of presenting with TBI compared with non-facial fracture patients.13 Therefore, it seems that facial fracture might act as a sentinel for TBI as hypothesized by some authors that suggested that facial fracture might be a predictable marker for TBI.24 In our investigation, FISS and MFISS proved to be useful and valuable assessment tools. Higher values of both FISS and MFISS revealed to be statistically associated with the diagnosis of TBI. In addition to this crucial finding from the literature, we managed to add further important information to the current literature. In fact, in our study, more severe facial damage (higher FISS 8 and MFISS values) was associated with traumatic brain injury, thanks to a positive correlation 8 between the severity of maxillofacial injuries and the occurrence of traumatic brain injury. This is of clinical importance as it indicates that in severely injured patients with severe and complex facial fractures, early neurosurgical/neurological assessment is most probably needed and emergency computed tomography should be performed without delay to prevent the morbidity associated with TBI. Quick neurological diagnosis and early intervention is fundamental to prevent or at least decrease the occurrence of avoidable complications as well as mortality and to give the most appropriate multidisciplinary treatment, as even a short duration of hypoxia and edema might lead to significant neurological deficits. It is important to consider that the incidence of head injury in patients with maxillofacial trauma might be attributed to the transfer of force from the facial skeleton to the cranium. The mechanism of force transmission that occurs through the head and the neck during facial trauma is not well

ͺ͹ understood.23 Traditionally, the face has been thought to have an impact absorbing property, thereby protecting the neurocranium from severe injury. Nevertheless, some authors have suggested that the facial skeleton may actually transmit the significant forces required to induce fractures of the facial skeleton directly to the neurocranium, resulting in serious brain injury.22 In the results we noted the sensitivity and specificity of different cut-off points for the FISS and MFISS. It is difficult to point one specific cut-off point as the best. The cut off point 3 and 5 for the FISS showed the best sensitivity and specificity. Using 3 as cut-off point the reliability to diagnose neurotrauma is higher than the other point. However, the patient number in our population having a FISS of 3 or higher is very high. It is questionable if we had to admitt all these patients to the department of neurology for an early neurosurgical/neurological assessment to identify 75% of all patients with a TBI. However, as we showed the results of different cut-off points for FISS and MFISS a clinician can choose which cut-off point suits better to their hospital protocols. The main limitations of the present study are due to the local and not fully national representativeness, as well as to the retrospective nature of the investigation. Nevertheless, the results found in this study are mostly in line with other studies, and suggest that the data might be useful for the development of protocols to prevent maxillofacial trauma accompanied with or without brain injury.

Conclusion

The results of our study seem to confirm that severe facial fractures are associated with traumatic brain injury. In fact, severe facial fractures mean more mechanical force insult and affect more severe injury to brain. Our data showed that despite the association between severity of the trauma and traumatic brain injury it is very difficult to identify a parameter or a set of parameters with a high sensitivity and specificity for diagnosing traumatic brain injuries.

ͺͺ References

1. Naveen Shankar A, Naveen Shankar V, Hedge N, Sharma, Prasad R. The pattern of the maxillofacial fractures - a multicenter retrospective study. J Craniomaxillofac Surg 2011;40(8):675–679.

2. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. An etiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40(6):e165–e169.

3. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(2):166–170.

4. Bali R, Sharma P, Garg A, Dhillon G. A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India. J Inj Violence Res 2013;5(2):108–116.

5. Hussain K, Wijetunge DB, Grubnic S, Jackson IT. A comprehensive analysis of craniofacial trauma. J Trauma 1994;36(1):34–47.

6. Bogusiak K, Arkuszewski P. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 2010;21(4):1018–1023.

7. Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26(6):E7.

8. Davidoff G, Jakubowski M, Thomas D, Alpert M. The spectrum of closed-head injuries in facial trauma victims: incidence and impact. Ann Emerg Med 1988;17(1):6–9.

9. Salentijn EG, Peerdeman S, Boffano P, van den Bergh B, Forouzanfar T. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 2014;42(6):705–710.

10. Salentijn EG, Collin JD, Boffano P, Forouzanfar T. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: Complications and treatment. J Craniomaxillofac Surg 2014;(42(8):1717–1722.

11. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9543 cases with 21067 injuries. J Craniomaxillofac Surg 2003;31(1):51–61.

12. Thoren H, Snall J, Salo J, Suominen-Taipale L, Kormi E, Lindqvist C, Törnwall J. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 2010;68(4):805–810.

13. Rajandram RK, Syed OSN, Rashdi MF, Abdul JMN. Maxillofacial injuries and traumatic brain injury - a pilot study. Dent Traumatol 2014;30(2):128–132.

14. Rajendra PB, Mathew TP, Agrawal A, Sabharawal G. Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases. J Emerg Trauma Shock. 2009;2(2):89–94.

15. Haug RH, Savage JD, Likavec MJ, Conforti PJ. A review of 100 closed head injuries associated with facial fractures. J Oral Maxillofac Surg 1992;50(3):218–222.

16. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR. The impact-absorbing effects of facial fractures in closed-head injuries. An analysis of 210 patients. J Neurosurg 1987;66(4):542–547.

17. Chang CJ, Chen YR, Noordhoff MS, Chang CN. Maxillary involvement in central craniofacial fractures with associated head injuries. 8 J Trauma 1994;37(5):807–811. 8 18. Zhang J, Zhang Y, El-Maaytah M, Ma L, Liu L, Zhou LD. Maxillofacial Injury Severity Score: proposal of a new scoring system. Int J Oral Maxillofac Surg 2006;35(2):109–114.

19. Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64(3):408–414.

20. Chen C, Zhang Y, An J-G, He Y, Gong X, Comparative study of four maxillofacial trauma scoring systems and expert score. J Oral Maxillofac Surg 2014;72(11):2212–2220.

21. Sahni V, Maxillofacial Trauma Scoring Systems: A Review. Injury 2016;47(7):1388–1392.

22. Tse KM, Tan LB, Lee SJ, Lim SP, Lee HP. Investigation of the relationship between facial injuries and traumatic brain injuries using a realistic subject-specific finite element head model. Accid Anal Prev 2015;79:13–32.

23. Grant AL, Ranger A, Young GB, Yazdani A. Incidence of major and minor brain injuries in facial fractures. J Craniofac Surg 2012;23(5):1324–1328.

24. You N, Choi MS, Roh TH, Jeong D, Kim SH. Severe facial fracture is related to severe traumatic brain injury. World Neurosurg 2018;111;e47–e52.

25. Aladelusi T, Akinmoladun V, Olusanya A, Akadiri O, Fasola A. Analysis of road traffic crashes-related maxillofacial injuries severity and concomitant injuries in 201 patients seen at the UCH, Ibadan. Craniomaxillofac Trauma Reconstr 2014;7(4):284–289.

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Chapter 9

The use of neuron-specific enolase to predict mild brain injury in motorcycle crash patients with maxillofacial fractures: A pilot study

This is an edited version of the manuscript: Muhammad Ruslin, Jan Wolff, Harmas Y. Yusuf, Muhammad Z. Arifin, Paolo Boffano, Tymour Forouzanfar The use of neuron-specific enolase to predict mild brain injury in motorcycle crash patients with maxillofacial fractures: A pilot study Accepted for Publication

ͻͳ Abstract

Introduction: Mild traumatic brain injury (TBI) is common but accurate diagnosis and its clinical consequences have been a problematic, maxillofacial trauma does have an association with traumatic brain injury. Neuron-specific enolase (NSE) have been developed to evaluate neuronal damage. The aim of this study was to investigate the accuracy of neuron-specific enolase (NSE) serum levels to detect mild brain injury of patients with sustained maxillofacial fractures during motor vehicle accidents.

Methods: Blood samples were drawn from 40 healthy (control group) and 48 trauma patients who had sustained isolated maxillofacial fractures and mild brain injury assessed employing Glasgow Coma Scale. In the trauma group, correlations between the NSE serum values and different facial fracture sites were assessed.

Results: The mean NSE serum level in the group of 48 patients who had sustained maxillofacial fracture was 13.12 ng/ml with SD (standard deviation) of 9.68 ranging from 3.19 to 54.51 ng/ml. These values were significantly higher than those measured in the healthy control group (p <0.001). The mean NSE serum levels in the lower part of the facial skeleton (15.44 ng/ml with SD of 15.34) were higher than those in the upper facial part (12.42 ng/ml with SD 7.68); and the mean NSE level in middle-and lower part 11.97 ng/ml with SD 5.63, was higher than in the middle part (7.88 with SD 2.64).

Conclusion: IncreasedNSE serum NSE levels serum can levelsbe observed can be inobserved patients in who patients have whosustained have sustainedmaxillofacial maxillofacial fractures andfractures mild andbrain mild injury. brain Injury.

ͻʹ

Introduction

Mild traumatic brain injury (TBI) is common but accurate diagnosis and its clinical consequences have been a problematic. Mild TBI causes transient neurophysiologic brain dysfunction, sometimes with structural axonal and neuronal damage. Clinically mild TBI includes acute early phase post- traumatic symptoms such as headache, dizziness, imbalance, fatigue, sleep disruption, and impaired cognition. These symptoms resolve for several days even weeks and they are largely related to brain trauma and concomitant injuries. The late phase post-traumatic symptoms exist in minority of patients consist of somatic, emotional, and cognitive symptoms. Effective early phase management may prevent or limit the later phase symptoms and should include education about symptoms and expectations for recovery, as well as recommendations for activity modifications.1 In a recent retrospective study, Salentijn et al.2 found that maxillofacial trauma does have an association with traumatic brain injury. In comparison to the overall maxillofacial trauma population, their results demonstrate that frontal sinus fractures are more commonly diagnosed in brain injury and the location of impact in these kinds of traumas is potentially considered to be the cause. Despite substantial progress in post-traumatic neuro-monitoring it still remains difficult to quantify the exact extent of brain injury sustained during such fractures. To date the Glasgow Coma Scale (GCS) is still considered to be the gold standard in assessing the consciousness level of patients having sustained traumatic brain injury after trauma.3 However the GCS scale lacks of specificity to assess the exact magnitude of brain injury sustained during the traumatic brain. Even with the current used scale like the Marshall CT classification, such injuries still remain difficult to assess.4 Despite numerous studies on maxillofacial trauma accompanies with traumatic brain injury have been carried out,5-9 there is still a lack of information on undetected mild brain injury to patients with maxillofacial trauma after vehicle accidents. Knowing the consequences of untreated mild brain injury, it is very important to detect in early stage the brain injuries exist in maxillofacial trauma patients. Therefore, this study is especially carried out to detect mild degree of brain injury in patients with maxillofacial trauma after vehicle accidents. 9 In recent years, several new biomarkers have been developed to evaluate neuronal injuries and have ever since also become increasingly important supplements to the GCS. Neuron-specific enolase (NSE) is one of such protein-based enzyme found primarily within neurons and it is commonly used to assess the grade of neuronal damage after trauma.10-14 Increased concentration 9 of NSE can be measured in the cerebrospinal fluid and in the peripheral blood after neuronal damage in which it provides a quick and reliable laboratory indicator of the degree of brain cell damage sustained after trauma.15

The present pilot study was aimed at investigating the neuron-specific enolase serum levels in patients that had sustained maxillofacial fractures during motor vehicle accidents. Furthermore, we

ͻ͵ also assessed the differences of NSE serum values at different maxillofacial fracture sites. The eventual future aim would be to investigate prospectively the accuracy neuron-specific biomarkers in detecting mild brain injury in patients with maxillofacial trauma.

Material and Methods

Ethical approval was granted by the Health Research Ethics Committee at the Faculty of Medicine University of Padjadjaran / Dr. Hasan Sadikin General Hospital Bandung, Indonesia. The first group consisted of 48 adult patients who had sustained isolated maxillofacial fractures during motor vehicle accidents in the Bandung area. The fracture locations were divided into three parts: upper, middle and lower part. The upper part of facial skeleton comprising the frontal bone, the middle part comprising the midfacial bone: the maxilla, the nasoethmoid, and lateral midfacial bone-zygoma, and the lower part comprising the mandible. The second group of 40 control patients were healthy adult subjects with no history of facial trauma that were undergoing routine medical checkup at the Dr. Hasan Sadikin Hospital in Bandung. A detail analysis was carried out on all patients who satisfied the inclusion and exclusion criteria. The inclusion criteria for the first group are all patients whom presented with isolated maxillofacial injuries during motor vehicle accidents, structural imaging normal, loss of consciousness 0–30 min, alteration of consciousness/mental state up to 24 h, and post-traumatic amnesia 0–1 day. Only patients with a mild brain injury (GCS score 13 – 15) were included in this study. Patients with multiple traumas with Abbreviated Injury Score (AIS) ≥ 3 in other body region were excluded from the study. Prognosis of all patients was good. The brain injury was measured using the GCS. The GCS was introduced in 1974 as a method for determining objectively the severity of brain dysfunction and coma six hours after the occurrence of the head trauma. The GCS scale is composed of three different tests namely: eye, verbal, and motor response. Mild available score is 13 – 15, moderate score is 9 – 12 and severe if its score range is < 9.3 All blood samples were withdrawn from both patient groups by peripheral vein puncture. All NSE measurements were performed with an electrochemiluminescence immunoassay (ECLIA), using a sandwich technique in duplicate, with NSE kits (Roche, Mannheim, Germany) and the Elecsys 2010 analyzer (Roche Diagnostics, Mannheim, Germany). Since the half-life of NSE in the serum is approximately 48 hours,16 all trauma and healthy patients in this study underwent NSE screening within 24 hours. The time from injury to blood drawn in one trauma patient in our study was in 30 hours, one trauma patient was in 28 hours and the rest of them drawn in < 24 hours. Furthermore it must be noted

ͻͶ that NSE values vary from hour to hour after trauma and subsequently reflect the status of the axonal injury.17 The Statistical analysis was performed using SPSS (IBM). The Mann-Whitney test was used to assess the NSE serum levels of all patients who had sustained maxillofacial fractures and were subsequently compared to the healthy group. Furthermore, the Kruskal-Wallis test was used to calculate the mean increase in NSE serum levels in correlation to the location of maxillofacial fractures. Finally the Spearman ranked correlation test was used to calculate the correlation between the increased serum NSE levels and location of maxillofacial fracture in adult patients with mild head injury. P values of (p 0.05) were considered to be statistically significant.

Results

In this study consisting of 88 participants, the mean age of the 48 subjects who had sustained a maxillofacial fracture was 27.56 years ranging from 19-65 years; whereas the mean age of healthy subjects was 37.12 years, ranging from 19-65 years. A total of 62 patients with maxillofacial injuries were surgically treated in the three months study period. However, eleven patients had to be excluded from the study due to the incomplete medical data. Two patients were excluded due to pulmonary disease and one patient was excluded because he decided to leave the hospital before completing his treatment. The trauma group consisted of 41 males and 7 females and the healthy group consisted of 24 males and 16 females. The mean NSE serum levels in the trauma group was 13.12 ± 9.68 (SD) ng/ml which proved to be significantly higher than the healthy control group, i.e. 7.72 ± 1.82 (SD) ng/ml with SD (p<0.001) (Table 9.1.).

Table 9.1. NSE serum levels in the trauma and healthy patient groups NSE Results (ng/mL) Group Range p Value Mean SD 9 Trauma Group (n=48) 13.12 9.68 3.19-54.51 <0.001 9 Healthy Group (n=40) 7.72 1.82 4.27-10.70

The mean NSE serum values recorded in the male trauma group differed from those in the female trauma group, however the results were not significant (p > 0.05) (Table 9.2.).

ͻͷ

Table 9.2. Serum NSE levels in patients with facial injury divided into gender and fracture site NSE Results (ng/mL) Group Significance p Value Mean SD

Gender ZMW=0.174 0.183 * Male (n=41) 11.13 9.40 Female (n=7) 17.57 10.77

2 Fractures site X KW=9.518 0.049 ** Upper (n=17) 12.42 7.68 Middle (n=22) 7.88 2.64 Lower (n=9) 15.44 15.34

* ZMW = Mann-Whitney test

2 ** X KW = Kruskall-Wallis test

Table 9.3. demonstrates that the mean NSE values in patients with a lower facial fracture and patients with a combination of fractures in all three facial parts were significantly higher than the mean NSE recorded in patients with only upper facial fractures (Kruskall-Wallis) (p < 0.05).

Table 9.3. The correlation between NSE serum level and the fracture location

Correlation with NSE rs p value Location Upper (n=17) 0.25 0.091 Middle (n=22) 0.05 0.726 Lower (n=9) 0.23 0.121 Total 0.33 0.020

* rs Spearman ranked correlation coefficient

As shown in Table 9.3. the Spearman ranked correlation test resulted in a significant correlation between patients with fractures of all the three part (upper, middle and lower) of the facial skeleton and NSE (P = 0.02).

Discussion

Maxillofacial fractures are mainly caused by motor vehicle accidents and can be accompanied with traumatic brain injury.5-9 There is still a lack of information on undetected mild brain injury. Mild brain injury has severe future consequences when it is not detected in an early stage. In our pilot study we aimed at investigating the accuracy of NSE in detecting mild brain injury. The NSE level

96 ͻ͸ of patients with maxillofacial fractures accompanied with mild brain injury were compared to the levels of normal persons. The findings indicate that patients having sustained facial fractures have higher NSE values than healthy controls. Furthermore, the results of this study showed no gender differences in serum NSE levels in adult patients that had sustained facial fractures. These results are comparable to those reported by Hayes10 and Wu et al.12 suggest that serum NSE levels are not gender bases. Furthermore, the NSE levels in patients with facial fractures differed significantly depending on the location of the facial fractures. The lowest NSE levels were recorded in the midfacial part implying that the midfacial bony structures absorb traumatic forces better than other bony structures and subsequently protect the neurocranium from heavy trauma.18 The midface anatomy is unique in its scaffold-like structure and offers vertical supporting structures, i.e., nasomaxillar, zigomaticomaxillar, and pterigomaxillar buttresses; and horizontal supporting structures, i.e., lateral anthrum, medial nasal wall, and zygomatic arc.19 The aforementioned differences in sight specific NSE values can be due to biomechanical differences in the bony structures of the upper facial area when compared to the mid face region. The upper facial bones often lack of sufficient amount of cancellous bone, therefore the scaffold like structure of the mid face respond with a minimum deformation to a load increase induced by a trauma. This lack of deformation subsequently leads to higher forces induced on the skull and increases the risk of head injury as previously reported by Lee et al.18 and by Salentijn et al.2 Interestingly all patients who had sustained blows to their lower jaws in our study had higher NSE values. These results agree with a study held by Keenan et al.20 indicating that facial fractures are markers to a high risk of brain injury. However, these results are contradictive to the same study mentioned earlier by Lee et al.18 who reported that patients who had sustained injuries in the lower facial part (mandible) had less risk for sustaining a head injury. One explanation for the higher NSE values in the patients who sustained fractures in the lower jaw could be due to the direct energy transmission into the skull base and brain. Upon impact to the lower jaw forces are transmitted through the condyles into the disks and directly into the temporal bone, hence skull base causing a possible increase in the NSE serum values. Interestingly in clinical settings, mandible fractures are often classified as being less problematic than midface traumas. A recent study by Salentijn et al.2 reported that fractures of the midface and upper third 9 part of the skull are more prone to cause brain injury than mandibular fractures. The results of the present study are not in good agreement with the aforementioned clinical studies by Salentijn et al.2 In several recent articles, authors state that NSE is released into the blood by hemolysis, which may be a serious source of error in some cases.21 Furthermore, increases in NSE levels have been observed in multiple types of trauma with and without traumatic brain injury, limiting its ability to properly discriminate the magnitude of brain injury.21 As our pilot study is limited in NSE investigation level in patients with maxillofacial injury without mild brain injury, further research using a more comparable control group should conduct to decisively sum up a conclusion on this

ͻ͹ issue. In addition, the number of the case involved in this study is limited, thus should be enhanced in subsequent research.

Conclusion

Despite the shortcomings of the present pilot study, it can carefully be concluded that an increase in NSE serum levels can be observed in patients who have sustained maxillofacial fractures and mild brain injury. Further, our findings suggest that patients with maxillofacial fractures can sustain mild brain injuries which can remain undiagnosed in clinical settings. However, to draw firm conclusion on the accuracy of NSE measurement in discriminating between patients with maxillofacial trauma accompanied with mild brain injury and patients with maxillofacial injury without brain injury, a prospective study consisting of these two group of patients is mandatory.

ͻͺ References

1. Katz DI, Cohen SI, Alexander MP. Mild traumatic brain injury. Handb Clin Neurol. 2015;127:131–56. 2. Salentijn EG, Peerdeman SM, Boffano P, van den Bergh B. A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 2014;42(6):705–710. 3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81–84. 4. Kobeissy FH, Ottens AK, Zhang Z, Liu MC, Denslow ND, Dave JR, Tortella FC, Hayes RL, Wang KKW. Novel differential neuroproteomics analysis of traumatic brain injury in rats. Mol Cell Proteomics 2006;5(10):1887–1898. 5. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31(1):51–61. 6. Thoren H, Snall J, Salo J, Suominen-Taipale L, Kormi E, Lindqvist C, Tornwall J. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 2010;68(4):805–810. 7. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R. The Pattern of the maxillofacial fractures – A multicenter retrospective study. J Craniomaxillofac Surg 2012;40(8):675–679. 8. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69(10):2613–2618. 9. Rajandram RK, Syed OSN, Rashdi MF, Abdul Jabar MN. Maxillofacial injuries and traumatic brain injury – a pilot study. Dent Traumatol 2014;30(2):128–132. 10. Hayes RL. Biochemical markers of brain injury: applications to combat casualty care. Paper presented at: the RTO HFM Symposium on combat casualty care in ground based tactical situations: Trauma technology and emergency medical procedures; August 16–18, 2004;16–8; St. Pete Beach, USA 11. Pineda JA, Wang KK, Hayes RL. Biomarkers of proteolytic damage following traumatic brain injury. Brain Pathol 2004;14(2):202– 209. 12. Wu YC, Zhao YB, Lu CZ, Qiao J, Tan YJ. Correlation between serum level of neuron-specific enolase and long-term functional outcome after acute cerebral infarction: prospective study. Hong Kong Med J. 2004;10:251–254. 13. Wang KK, Ottens AK, Liu MC, Lewis SB, Meegan C, Oli MW, Tortella FC, Hayes RL. Proteomic identification of biomarkers of traumatic brain injury. Expert Rev Proteomics 2005;2(4):603–614. 14. Laterza OF, Modur VR, Crimmins DL, Olander JV, Landt Y, Lee JM, Ladenson JH. Identification of novel brain biomarkers. Clin Chem. 2006;52(9):1713–1721. 15. Ergün R, Bostanci U, Akdemir G, Beşkonakli E, Kaptanoğlu E, Gürsoy F, Taşkin Y. Prognostic value of serum neuron-specific enolase after head injury. Neural Res 1998;20(5):418–420. 16. Wunderlich MT, Ebert AD, Kratz T, Goertler M, Jost S, Herrmann M. Early neurobehavioral outcome after stroke is related to release of neurobiochemical markers of brain damage. Stroke 1999;30(6):1190–1195. 17. Bazarian JJ, Merchant-Borna K. Tau, s-100 calcium-binding protein B, and neuron-specific enolase as biomarkers of concussion. JAMA Neurol 2014;71(7):925–926. 18. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR. The impact-absorbing effect of facial fractures in closed-head injuries. J Neurosurg 1987;66(4):542–547. 19. Plaisier BR, Punjabi AP, Super DM, Haug RH. The relationship between facial fractures and death from neurologic injury. J Oral Maxillofac Surg 2000;58(7):708–712. 20. Keenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP. Does the face protect the brain? A case-control study of traumatic brain injury and facial fractures. Arch Surg 1999;134(1):14–17. 21. Yokobori S, Hosein K, Burks S, Sharma I, Gajavelli S, Bullock R. Biomarkers for the clinical differential diagnosis in traumatic brain injury; a systematic review. CNS Neurosci Ther 2013;19(8):556–565. 9 9

ͻͻ 100

Chapter 10

The influence of helmet on the prevention of maxillofacial fractures sustained during motorcycle accidents

This is an edited version of the manuscript: Muhammad Ruslin, Harmas Y. Yusuf, Muhammad Z. Arifin, Jan Wolff, Paolo Boffano, Tymour Forouzanfar The influence of helmet design on the prevention of maxillofacial fractures sustained during motorcycle accidents Accepted for Publication

ͳͲͳ Abstract Introduction: Traffic accidents are among the main etiologic factors of maxillofacial injuries. Of all the different types of motor vehicles used worldwide, motorcycle riders sustain the most serious injuries in the head and neck area. Therefore, this study aimed to assess the effect of half-coverage helmet use in motorcycle accidents and to investigate the difference in neuron-specific enolase serum levels in helmeted and unhelmeted person who had sustained maxillofacial fractures during motorcycle accidents.

Methods: The study comprised of half-coverage helmeted and unhelmeted patients who had sustained maxillofacial fractures during motorcycle accidents. Only hospitalized patients with maxillofacial fractures and a mild head injury that had been surgically treated within 48 hours were included in this study. The riders whose helmet flied out before their head hit the ground were included as unhelmetted patients. All patients who had sustained moderate or severe head injuries were excluded from the study.

Results: A total of 48 subjects (22 helmeted and 26 unhelmeted) sustained maxillofacial fractures were divided into three parts: upper, middle, and lower facial. All patients were scored using the Glasgow Coma Scale upon arrival at the hospital. The most prevalent maxillofacial fracture site in helmeted group was the mid-face (40.9%) and the upper-middle-lower face (26.9%) in unhelmeted group. There was no statistical significant difference between neuron-specific enolase serum levels in helmeted group (11.5 mg/ml) compared to unhelmeted group (14.49 ng/ml) (p > 0.05).

Conclusion: Half-coverage helmets provided motorcyclists with only limited protection in the head and facial area. Unhelmeted motorcycle riders sustained comparable injuries compared to half-coverage helmeted users. It should be noted that the same clinicians carried out this investigation, and the same protocol was used throughout the present study.

102 ͳͲʹ

Introduction

Due to the increase of motor vehicle ownership and rapid economic development, the number of road traffic injuries is unexpectedly increasing; significantly in the next decade.1 Traffic accidents are among the main etiologic factors of maxillofacial injuries and account for 34.42 – 80.14% of all skeletal and soft tissue injuries in the facial area.2 Of all the different types of motor vehicles used worldwide, motorcycle riders sustain the most serious injuries in the head and neck area which often lead to a disability or in some cases lead to mortality.3 Previous studies focused on the assessment of motorcycle accidents and have found a significant reduction in the risk of head and brain injuries in helmeted motorcycle riders compared to unhelmeted persons.4-6 Another group reported that wearing a standard good quality motorcycle helmet reduces the risk of mortality by 40% and the risk of serious injury by over 70%.7 Conrad et al.8 conclude that although motorcycle riders appear to comply with the motorcycle helmet law, it is a "token compliance," less than 50% of riders were maximally protected by helmets and very little safety consciousness was found among riders.8 Assessing the exact extent of brain damage caused after motorcycle accidents remains a challenge. In recent years several new biomarkers have been developed to assess the degree of neuronal injury sustained during a trauma. These biomarkers are becoming increasingly important as supplements for the Glasgow Coma Scale (GCS). Another existing biomarker is neuron-specific enolase (NSE), a protein-based enzyme found within neurons that can be used to quantify the degree of neuronal damage sustained after a head trauma.9-12 Increased concentration of NSE can be measured in the cerebrospinal fluid and in peripheral blood after trauma; hence, neuronal damage offers a quick and reliable method of assessing the degree of brain cell damage sustained after motorcycle accidents.13 The aims of this study were to assess the effects of different helmet designs (full and half-coverage helmets) in motorcycle accidents and to carry out further investigation on the difference NSE serum levels in half-coverage helmeted and unhelmeted persons that had sustained maxillofacial fractures during motorcycle accidents. Furthermore, correlations between NSE serum values and different maxillofacial fracture sites were also assessed.

103ͳͲ͵ Material and Methods

This study was approved by the Health Research Ethics Committee of Medical faculty, the University of Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, Indonesia. The study comprised of half-coverage helmeted and unhelmeted patients who had sustained maxillofacial fractures during motorcycle accidents at the urban Bandung area in Indonesia. Only hospitalized patients with maxillofacial fractures and a mild head injury that had been surgically treated within 48 hours were included in this study. The riders whose helmet flied out before their head hit the ground were included as unhelmetted patients. All patients who had sustained moderate or severe head injuries were excluded from the study. Furthermore, multiple trauma and alcoholized patients were excluded from the study. The maxillofacial fractures were divided into three parts upper, middle, and lower facial. The upper part of facial skeleton comprising the frontal bone, the middle part comprising the midfacial bone: the maxilla, the nasoethmoid, and lateral midfacial bone- zygoma, and the lower part comprising the mandible. All patients in this study were scored using the GCS upon arrival at the hospital. Furthermore, computed tomography scans of all patients were also performed. Blood samples were taken from all studied patients and centrifuged for 10 minutes at 2.500 rotations per minute. Neuron-specific enolase measurements were performed with an electrochemiluminescence immunoassay (ECLIA) using a sandwich technique in duplicate with NSE kits (Roche, Mannheim, Germany) and the Elecsys 2010 analyzer (Roche Diagnostics, Mannheim, Germany). This study underwent NSE screening within 24 hours since the half-life of NSE in the serum is approximately 48 hours.14 The NSE cut-off value is 10 ng/ml.15 Statistical analyses were performed using statistical package for social science (SPSS) version 22.0. The Chi-Square test was used to assess the gender, age, and site of fracture of helmeted motorcyclist. Furthermore, the independent t-test was used to calculate the mean admission of GCS, life-time NSE, and NSE results in correlation with the helmeted motorcyclist, and finally the two-way ANOVA test was used to calculate the NSE serum value related to half-coverage helmeted (Figure 10.1A.) and unhelmeted motorcyclist that had sustained maxillofacial fractures.

Figure 10.1. Types of helmet: A. Half-coverage helmet. B. Full-coverage helmet

104 ͳͲͶ Results

A total of 62 patients with mild head injuries were surgically treated in the three months study period. However, fourteen patients should be excluded from the study since eleven patients had incomplete medical data, two patients have pulmonary disease and one patient decided to leave the hospital before completing his treatment. From all subjects (48 patients) included in this study, it has been found that 45% (22 patients) were half-coverage helmeted and 54% (26 patients) unhelmeted. The group consisted of 41 males patients (85%) and seven females (14%) with a mean age was 27.57 years old ranging from 19 to 65 years old. The most prevalent group was between 16–25 years old with 45% (22 subjects) were half-coverage helmeted and 54% (26 subjects) were unhelmeted. The most prevalent maxillofacial fracture site was the mid-face 40.9% in the half-coverage helmeted group and 26.9% in upper-middle-lower in the unhelmeted group (Figure 10.2.).

Half-coverage helmeted Unhelmeted

10 Figure 10.2. Half-coverage helmeted and unhelmeted distribution stratified according to maxillofacial fractures site 10

All patients sustained a mild head injury during the traffic accident with the mean GCS 13.95 values upon admission were 13.95 in the half-coverage helmeted group and 13.73 in the unhelmeted group. The mean life-time NSE values were 10.89 hours in the half-coverage helmeted and 13.24 hours in the unhelmeted group. Furthermore, the mean NSE serum levels of the patients who had sustained a maxillofacial fracture was 11.52 ng/ml in the half-coverage

105ͳͲͷ helmeted group and 14.49 ng/ml in the unhelmeted group; however, there was no statistically significant difference between the two groups (p > 0.05) (Table 10.2.).

Table 10.1. Patients’ demographic and maxillofacial fractures, GCS, and NSE characteristics of half-coverage helmeted motorcyclist compared with unhelmeted motorcyclist involved

Half-coverage helmeted Unhelmeted Characteristic p-value (n = 22) (n = 26) Gender Male 18 (81.8%) 23 (88.5%) 0.516a Female 4 (18.2%) 3 (11.5%) - Age Group (years) 16–25 9 (41%) 17 (65.4%) 0.342a 26–35 8 (36.4%) 4 (15.4%) - 36–45 3 (13.6%) 4 (15.4%) - 46–55 1 (4.5%) 1 (3.8%) - 56–65 1 (4.5%) - - Fractures site Upper 5 (22.7%) 4 (15.4%) 0.118a Upper-middle - - - Upper-lower - - - Upper-middle-lower 1 (4.5%) 7 (26.9%) - Middle 9 (40.9%) 4 (15.4%) - Middle-lower 3 (13.6%) 6 (23.1%) - Lower 4 (18.2%) 5 (19.2%) - Mean admission GCS 13.95 (0.58) 13.73 (0.72) 0.239b Mean life-time NSE 10.98 (5.26) 13.24 (4.88) 0.133b Mean NSE results 11.52 (6.83) 14.49 (11.52) 0.294b a) Chi-Square test; b) independent t-test, p < 0.05

The two-way ANOVA analyses showed that the NSE serum values in the half-coverage helmeted subjects who had sustained maxillofacial fractures in the upper-middle-lower sites were 33.01 ng/ml. These values were slightly higher than those recorded in the unhelmeted group 19.45 ng/ml; however, there was no statistical significant difference between the groups (p > 0.05) (Table 10.2.).

Table 10.2. Half-coverage helmeted and unhelmeted motorcyclist related NSE serum level and maxillofacial fracture site NSE Fracture site p-value Half-coverage helmeted Unhelmeted Upper 12.91 11.82 Upper-middle - - Upper-lower - - Upper-middle-lower 33.01 19.45 0.480 Middle 8.82 5.79 Middle-lower 8.17 13.87 Lower 13.01 17.40

*) p-value two-way ANOVA, p < 0.05

The NSE serum values in the unhelmeted subjects who had sustained maxillofacial fractures in the lower sites were 17.40 ng/ml. These values were slightly higher than those recorded in the half- coverage helmeted group 13.01 ng/ml; however, there was no statistical significant difference between the groups (p > 0.05) (Table 10.2.).

106 ͳͲ͸ Discussion

Motorcycles are the fastest growing sector of motor vehicles worldwide and comprise the majority of all motor vehicles in low- and middle- income countries.16 This study revealed that males (half-coverage helmeted 81.8% and unhelmeted 88.5%) are more frequently subjected to maxillofacial fractures than females (half-coverage helmeted 18.2% and unhelmeted 11.5%). Furthermore, maxillofacial fractures resulting from motorcycle accidents are most common amongst patients aged in the range of 16–25. These results, however, differed from those reported by Cavalcante et al.17 who studied the influence of helmets on facial trauma in motorcycle accidents and reported that most victims were between 21 and 40 years old (62.9%). A recent study by Cavalcante et al.17 reported that (94.5%) of the patients were male and the majority of patients were using a helmet (80.1%) during the accident. Furthermore, Conrad et al.8 reported that motorcycle riders in the urban Yogyakarta area in Indonesia did not always wear helmets especially at night when no police were around. The main reasons for not wearing helmets were discomfort and absence of police surveillance. One of the findings in our study shows that half-coverage helmets provide limited protection against head and brain injuries. Interestingly there is no significant difference between the half- coverage helmeted and unhelmeted group (mean GCS is 13.95 for half-coverage helmeted and 13.73 for unhelmeted). Nevertheless, intracranial cerebral injury; intracranial hemorrhage; and face, skull vault, and cervical spine injuries are more likely to be found in fatally injured to unhelmeted motorcyclist compared to helmeted motorcyclist.18 However, a helmet is only effective when it remains on the head during the accident. Based on the findings of this study, continued efforts should be warranted to encourage the use of full coverage (Figure 10.1B.) motorcycle helmet in Bandung. One possible method of increasing the comfort of full coverage helmets is by developing lighter helmets with better ventilation especially in hot countries. One explanation for the higher incidence of facial fractures in the upper and the middle third of the face in the half-coverage helmeted group could be due to the fact that most patients probably did not strap their helmets properly and subsequently exposed their chin area unprotected. Nevertheless, the half-coverage helmeted subjects had lower NSE values when compared to unhelmeted subjects in this study. These finding demonstrated that half-coverage helmeted offers more brain protection than unhelmeted. Interestingly, the NSE serum values in the half-coverage 10 helmeted group who had sustained maxillofacial fractures in the upper-middle-lower sites were slightly higher than in the unhelmeted group of patients. It indicates that half-coverage helmeted does not protect the upper-middle-lower regions of the face and, half-coverage helmeted only protects the posterior parts of the head. Furthermore, the NSE serum values in the unhelmeted group that had sustained maxillofacial fractures in lower facial region were slightly higher than in the half-coverage helmeted group indicating that the helmet strap may have a positive damping

107ͳͲ͹ effect. The results of this study demonstrated that more concern should be given to helmet design (fracture driven design). This study has several limitations since some information was not gathered directly from the motorcycle riders experienced the accidents; hence, there are some measurement bias associated with observations of the speed, crash area of helmet, incorrect helmet uses, and rider characteristics. Many helmets may appear to be standard helmets on visual inspection but in fact they may lack those energy absorption layer that may protect the rider from injury in the event of an accident, nonetheless the prevalence of non-standard helmets may be underestimated. In addition, the number of the case involved in this study is limited. Futher, to drow firm conclusion on the protection of helmeted and unhelmeted motorcycle riders associated with maxillofacial trauma, more quantitative data is a mandatory.

Conclusion

In conclusion, the findings of this study revealed that half-coverage helmets provided motorcyclists with only limited protection in the head and facial area. Unhelmeted motorcycle riders sustained comparable injuries compared to half-coverage helmeted users. It should be noted that the same clinicians carried out this investigation, and the same protocol was used throughout the present study.

108 ͳͲͺ References 1. Ameratunga S, Hijar M, Norton R. Road-traffic injuries: confronting disparities to address a global-health problem. Lancet 2006; 367(9521):1533–1540. 2. Wood EB, Freer TJ. Incidence and aetiology of facial injuries resulting from motor vehicle accidents in Queensland for three-year period. Aust Dent J 2001;46(4):248–288. 3. World Health Organization. (2013a). Global status report on road safety 2013: Supporting a decade of action. Geneva, Switzerland: World Health Organization. 4. Rowland J, Rivara F, Salzberg P, Soderberg R, Maier R, Koepsell. Motorcycle helmet use and injury outcome and hospitalization costs from crashes in Washington State. Am J Public Health 1996;86(1):41–45. 5. Houston DJ, Richardson LE. Motorcyclist fatality rates and mandatory helmet-use laws. Accid Anal and Prev 2008;40(1):200–208. 6. Crompton JG, Bone C, Oyetunji T, Pollack KM, Bolorunduro O, Villegas C, Stevens K, Cornwell EE 3rd, Efron DT, Haut ER, Haider AH. Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth. J Am Coll Surg 2011;212(3):295– 300. 7. World Health Organization. (2103b, Janury 2). Road traffic injuries. Retrieved from http://www.who.int/mediacentre/factsheets/fs358/ 8. Conrad P, Bradshaw YS, Lamsudin R, Kasniyah N, Costello C. Helmets, injuries and cultural definitions: motorcycle injury in urban Indonesia. Accid Anal Prev 1996;28(2):193–200. 9. Hayes RL, Wang KKW, Tortella FC, Dave JR, Lu XCM. Biochemical markers of brain injury: applications to combat casualty care. Presented at the RTO HFM Symposium on combat casualty care in ground based tactical situations: Trauma technology and emergency medical procedures. USA, (2004).16–18. 10. Pineda JA, Wang KKW, Hayes RL. Biomarkers of proteolytic damage following traumatic brain injury. Brain Pathol 2004;14:202– 209. 11. Wu YC, Zhao YB, Lu CZ, Qiao J, Tan YJ. Correlation between serum level of neuron-specific enolase and long-term functional outcome after acute cerebral infarction: prospective study. Hong Kong Med J 2004;10:251–254. 12. Wang KK, Ottens AK, Liu MC, Lewis SB, Meegan C, Oli MW, Tortella FC, Hayes R. Proteomic identification of biomarkers of traumatic brain injury. Expert Rev Proteomics 2005;2(4):603–614. 13. Ergün R, Bostanci U, Akdemir G, Beşkonakli E, Kaptanoğlu E, Gürsoy F, Taşkin Y. Prognostic value of serum neuron-specific enolase after head injury. Neurol Res 1998;20(5):418–420. 14. Wunderlich MT, Ebert AD, Kratz T, Goertler M, Jost S, Herrman M. Early neurobehavioral outcome after stroke is related to release of neurobiochemical markers of brain damage. Stroke 1999;30:1190–1195. 15. Bazarian JJ, Merchant-Borna K. Tau, s-100 calcium-binding protein B, and neuron-specific enolase as biomarkers of concussion- reply. JAMA Neurol 2014;71(7):926–927. 16. De Rome L, Ivers R, Fitzharris M, Du W, Haworth N, Heritier S, Richardson D. Motorcycle protective clothing: protection from injury or just the weather? Accid Anal Prev 2011;43(6):1893–1900. 17. Cavalcante JR, Oka SC, de Santana Santos T, Dourado E, de Oliveira E Silva ED, Gomes AC. Influence of helmet use in facial trauma and moderate traumatic brain injury victims of motorcycle accidents. J Craniofac Surg 2012;23(4):982–985. 18. Richter M, Otte D, Lehmann U, Chinn B, Schuller E, Doyle D, Sturrock K, Krettek C. Head injury mechanisms in helmet-protected motorcyclists: prospective multicenter study. J Trauma 2001;51(5):949–958.

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109ͳͲͻ 110

Chapter 11

Summary, General discussion and Conclusion

ͳͳͳ Summary

Chapter 2 systematically reviews all papers published worldwide in the last 30 years on the distribution and characteristics of facial injuries related to motor-vehicle accidents (MVA). The percentage of MVA as etiological factors in epidemiological studies on maxillofacial injuries ranged between 11% to 85%. Overall, a progressively decreasing trend was observed, particularly in North America, Brazil, and Europe. The recent literature clearly shows a wide difference in the incidence of MVA-related facial fractures between developed countries (20% in Japan, 35.2% in the Netherlands, 11% in Ireland) and developing countries (72%–85% in India and 46.7% in China). Naturally, differences in regulations and their implementation make it difficult to fully compare these data.

Studies on the wearing of helmets by motorcyclists in urban areas have highlighted two main points: the effectiveness of laws intended to increase their use, and the protection helmets have provided against brain injuries and death.1,2 Legislation making helmet use compulsory for all motorcyclists is crucial to reducing the incidence of facial injuries in this category: previous articles have demonstrated that motorcycle accidents involving unhelmeted riders cause severe traumatic brain injury in 100% of the patients, followed by 63.3% of moped/scooter accidents. This may be due to the high velocity achieved by motorcycles in conjunction with their riders unwilling to wearing helmets, making them doubly vulnerable in trafﬁc.3,4

Injuries associated with traffic accidents are a problem in many countries, and their prevention is often a priority for the public health authorities.1,2,5-16 As Chapter 3 shows, MVAs caused the maxillofacial fractures of 326 of the 3260 patients admitted to the various different European centers during the study period. Naturally, the incidence of MVA-related maxillofacial trauma varied, with the maximum value that was encountered in Zagreb (18%), In most centers, however, the percentage of MVAs was approximately 10%. In comparison with the European literature, this was among the lowest values ever reported - a result that may confirm the decreasing incidence of MVA-related maxillofacial injuries in high-income countries. The most common causes of MVA- related maxillofacial injury mechanisms in high-income countries were car accidents (177 patients), followed by motorcycle accidents (91 patients), pedestrians (33 patients), and other/unknown (25 patients).

Chapter 4 and 5 highlight a second cause of maxillofacial injuries, maxillofacial fractures associated with sport-related injuries, and chapter 6 present the demographics and patterns of sport-related maxillofacial fractures in a multicenter study. The percentage of sport as a cause of facial fractures was higher in Europe and Oceania. The number of sport injuries involving males

112 ͳͳʹ also outnumbered that involving females. Comprising data on 108 patients with 128 maxillofacial fractures, our study in chapter 5 confirmed previous findings that sport is a major cause of maxillofacial injuries, in which the most common sport-related fractures were zygomatic complex fractures, followed by mandible fractures. Our finding that soccer and hockey were the most prominent causes of sport-related maxillofacial trauma is consistent with the large number of people playing soccer in the Netherlands.17,18 In chapter 6, we found soccer (33%) to be the sport most responsible for maxillofacial injuries, followed by rugby (18%) and skiing (12%). A noteworthy finding is that coronoid process fractures were observed only in soccer players, and not in other sports groups-possibly a consequense of the fact that impact against another player is the most common cause of accident in soccer.17 Our findings in this study are largely consistent with those of other studies, suggesting that the data may be useful for the development of protocols to prevent maxillofacial trauma in certain sports.

Chapter 7 evaluated all patients presenting with facial trauma accompanied by dental injury at the VU University Medical Center (VUmc) in Amsterdam, where 164 (23.2%) patients of the total 707 patients presented with dental injuries associated with facial fractures. We found that the prevalence of dental injury associated with facial fractures was higher than that found in numbers of previous studies (18.9% and 22.5%)19,20 except fort hat of Zhou et al.21 where the prevalence we found was lower (41.8%). We found mandibular condylar fractures, mandibular parasymphyseal fractures, Le Fort fractures, and mandibular body fractures to have a significantly higher association with dental injury, and zygomatic arch or zygomatic complex fractures to have a significantly lower association. In both groups-i.e., that with dental injury and that without- we also found that the lower third of the face was more susceptible to fractures than the upper two-thirds. A possible explanation for the higher incidence of facial fractures we found in the lower third of the face is that most patients in the Amsterdam area are treated for bicycle accidents and not for interpersonal violence. The highest incidence of injured teeth was in the maxilla. The teeth most affected were the maxillary incisors (33.1%), followed by the mandible incisors (13.6%), mandible molars (12.8%), and maxillary premolars (12.6%). Our results are largely in line with those in other published studies.19-23 11

In fractures of the alveolar process, the soft tissues and teeth are often damaged, thereby increasing the severity of craniofacial injuries. In our study, traffic accidents were the major cause of dental injuries. While the overall role of traffic accidents as a cause of facial bone fracture is known to have decreased and the overall number of facial bone fractures caused by violence and sport injuries to have increased, we found that injuries caused by two-wheeled motor vehicles 11 (TWMV) accidents had significantly increased and that sport-related accidents had significantly decreased. Although we did not find a significant difference between TWMV and sport-related

113ͳͳ͵ accidents, we also observed a slight and gradual increase over the study period in the number of markers of a high risk of brain injury. One explanation for the higher NSE values in the patients fractures caused by violence. Examination of the causes of maxillofacial fractures with associated who sustained fractures in the lower jaw may concern direct energy transmission into the skull dental injuries showed a similar trend: that violence was an increasing cause of such injuries.19-23 base and brain. Upon impact to the lower jaw, forces are transmitted through the condyles into the disks and directly into the temporal bone, and thust the skull base. This may increase NSE serum Chapter 8 assesses the prognostic values of two commonly used scoring systems-the values. Maxillofacial Injury Severity Score (MFISS) and Facial Injury Severity Scale (FISS)-in detecting brain injury and maxillofacial fractures patients at the VU Medical Center in Amsterdam. Between Chapter 10 of this study explores the effect of helmet use in bicycle and motorcycle accidents in 2002 and 2013, a total of 1326 patients affected by maxillofacial fractures were treated, 52 of preventing head injuries by reducing the impact of forces to the head.27 It also investigates the whom had been diagnosed with TBI. Each patient had been graded according to the MFISS and difference in NSE serum levels in helmeted and unhelmeted people who had sustained FISS. The mean value of MFISS 5.70 and that of FISS was 2.25. Motor vehicle accidents were the maxillofacial fractures during motorcycle accidents. According to injury site, a total of 48 subjects most frequent cause of TBI (22 patients; p < 0.05). Both values of MFISS and FISS were (22 helmeted and 26 unhelmeted) who had sustained such fractures were divided into three parts: statistically associated with the presence of TBI, we found both systems to be valuable upper, middle, and lower facial. Upon arrival in hospital, all were scored using the Glasgow Coma assessment tools for the predicting TBI. High-energy trauma, such as MVA, which causes multiple Scale (GCS). The most prevalent maxillofacial fracture site in the helmeted group was the mid-face and complex facial fractures (higher MFISS and FISS values), represents a higher risk of being (40.9%); in the unhelmeted grup it was upper-middle-lower face (26.9%) in. Although NSE serum associated with brain injuries. A recent study based on finite element analysis of the maxillofacial levels in helmeted group (11.5 mg/ml) did not differ significantly from those in the unhelmeted trauma associated with TBIs showed that the site and direction of facial impact played a key role in group (14.49 ng/ml) (p > 0.05), patients who had been wearing half-coverage helmets had lower determining the severity and location of the facial bone fracture, which in turns influenced the NSE values than those who had worn no helmet. This demonstrates that half-coverage helmets severity and location of the traumatic brain injury.24 offered more brain protection than no helmet.

As there is still little information on undetected mild brain injury in patients with maxillofacial trauma, chapter 9 investigates the accuracy of neuron-specific enolase (NSE) serum levels in detecting mild brain injury in patients with sustained maxillofacial fractures after motor vehicle accidents. Blood samples were drawn from 40 healthy patients (control group) and 48 trauma patients who had sustained isolated maxillofacial fractures and mild brain injury assessed with the Glasgow Coma Scale. In the trauma group, correlations between the NSE serum values and different facial fracture sites were assessed. The mean NSE serum level in the group of 48 patients who had sustained maxillofacial fracture was 13.12 ng/ml. These values were significantly higher than those measured in the healthy control group. The mean NSE serum levels in the lower part of the facial skeleton (15.44 ng/ml) were higher than those in the upper facial part; and the mean NSE 11 level in the middle-lower parts (11.97 ng/ml) was higher than that in the middle part. The NSE levels in patients with facial fractures also differed significantly according to the location of the facial fractures. The lowest NSE levels were recorded in the midfacial part, implying that the midfacial bony structures absorb traumatic forces better than other bony structures, and subsequently protect the neurocranium from heavy trauma.25

Interestingly, all the patients in our study who had sustained blows to their lower jaws had higher NSE values. These results agree with a study by Keenan et al.26 indicating that facial fractures are

114 ͳͳͶ ͳͳͷ markers of a high risk of brain injury. One explanation for the higher NSE values in the patients who sustained fractures in the lower jaw may concern direct energy transmission into the skull base and brain. Upon impact to the lower jaw, forces are transmitted through the condyles into the disks and directly into the temporal bone, and thust the skull base. This may increase NSE serum values.

Chapter 10 of this study explores the effect of helmet use in bicycle and motorcycle accidents in preventing head injuries by reducing the impact of forces to the head.27 It also investigates the difference in NSE serum levels in helmeted and unhelmeted people who had sustained maxillofacial fractures during motorcycle accidents. According to injury site, a total of 48 subjects (22 helmeted and 26 unhelmeted) who had sustained such fractures were divided into three parts: upper, middle, and lower facial. Upon arrival in hospital, all were scored using the Glasgow Coma Scale (GCS). The most prevalent maxillofacial fracture site in the helmeted group was the mid-face (40.9%); in the unhelmeted grup it was upper-middle-lower face (26.9%) in. Although NSE serum levels in helmeted group (11.5 mg/ml) did not differ significantly from those in the unhelmeted group (14.49 ng/ml) (p > 0.05), patients who had been wearing half-coverage helmets had lower NSE values than those who had worn no helmet. This demonstrates that half-coverage helmets offered more brain protection than no helmet.

115ͳͳͷ General Discussion

In short the aims of this theses were threefold. First, we investigated the incidence, epidemiology and concequences of facial trauma caused by traffic and sport related accidents. Second, the use of trauma severity measurements in detecting mild brain injury were assessed and third, the protective value of different helmets in motorcyclists was studied.

MVA Motorand Sport Vehicle accident and Sport related accident injury related injury The etiology of MVA gives us important information. The available data demonstrates that motor vehicle accidents are still one of the most important etiological factors for maxillofacial injuries. Nowadays, their incidence widely varies, as various factors are involved in the prevention of such accidents. In particular, not only road conditions, speed limits, and safety equipment, but also the characteristics of used vehicles, socioeconomic conditions and regulations about alcohol drinking before driving are fundamental for the prevalence of such injuries.7 A great difference in the incidence of MVA-related facial fractures between developed countries (20% in Japan, 35.2% in the Netherlands, 11% in Ireland) and developing countries (72–85% in India, 46.7% in China) can be easily observed.31 In past studies regarding European populations reported percentages ranging between 25% and 60%. The results of the presented multicenter study in this thesis however showed an incidence of 10 % in most centers. This result could confirm the progressive trend of increased use of protective measures like seat belts and helmets. Wearing a seat belt proved to be effective for preventing fatalities and generally decreasing the severity of injuries to the head or neck and to the trunk.1 Further, it reduces the risk of facial injury, however it should be noted that even proper seat belt use cannot prevent all oral and maxillofacial injuries in motor vehicle occupants. Concerning motorcycle accidents, the crucial role of helmets has to be acknowledged. On the market there are several types of helmets available, with their own advantages and disadvantages. All of them have in common that they can prevent head injuries, but in particular full-face helmets seem to be mostly effective in protecting the face.9,32

Sport accidents are an important etiological factor for maxillofacial injuries, especially in the richest areas of the world.5,21,30 Nowadays, their incidence widely varies, as various factors are involved from the socioeconomic conditions of the study population to the local preference and tradition of the sport, as some contact sports like rugby are naturally more at risk of facial injuries in comparison with others.33 A great difference in the incidence of sport related facial fractures between developed countries (18% in New Zealand, 35% in Ireland, 31% in Austria, 14% in Japan) and developing countries (0.5% in Pakistan, 0.8% in India, 2.6% in Tanzania) can be easily observed. However, it is quite interesting to notice that across the last 20 years the incidence in the

116 ͳͳ͸ respective geographical areas seems to be stable, in contrast with the evolution of MVA, that are decreasing. Soccer is the most frequently responsible sport for maxillofacial fractures. This result is naturally influenced by the wide diffusion of soccer in the considered countries (France, Greece, Italy, South Korea, Ireland, and The Netherlands).33-40 Further, although the use of simple preventive devices such as helmets, and mouth guards have proven to prevent facial fractures, athletes still decide not to wear them, or do not know which is best, or choose a poorly fitting device

Finally, concerning the fractures type, from the analysis of the considered studies on MVA and sport related injuries a predominance of mandibular fractures33-37 followed by midfacial fractures was observed.39-40

Trauma severity measurement Trauma severity scores and NSE blood level could be of use as an indicators for brain injury.42-46 However to implement these measurement as standard assessments in patients with facial trauma more prospective studies are required. Our assessment of the prognostic value of MFISS47-49 and FISS48 during the detection of brain injury and maxillofacial fractures showed that MFISS and FISS were valuable assessment tools for diagnosing TBI, and that higher MFISS and FISS were associated with a higher TBI cases. This is of clinical importance. In severely injured patients with severe and complex facial fractures, it indicates that early neurosurgical/neurological assessment is almost certainly needed, and that emergency computed tomography should be performed without delay to prevent the morbidity associated with TBI. However, for further use, the clinician should choose the cut-off point with the best sensitivity and specificity fitting in the hospital policy.

With regard to protection of the brain, we found that a half-coverage helmet offers more brain protection than no helmet.49 Interestingly the NSE serum values in those who had sustained maxillofacial fractures to the upper-middle-lower sites when wearing half-coverage helmets were slightly higher than in those who had not been wearing a helmet. The NSE serum values in the unhelmeted group whose maxillofacial fractures that had been sustained in the lower facial region 11 were also slightly higher than in the half-coverage helmeted group, indicating that the helmet strap may have a positive damping effect. These results stress the need for greater attention to be paid to helmet design (i.e., fracture-driven design).

Concerning the association between maxillofacial fracture and TBI, our findings suggest that 11 patients with maxillofacial fractures can sustain mild brain injuries that remain undiagnosed in a clinical settings. While an increase in NSE serum levels can be observed in patients who have sustained maxillofacial fractures and mild brain injury, firm conclusions on the accuracy of NSE

117 ͳͳ͹ measurement in discriminating between patients with maxillofacial trauma accompanied by mild brain injury and in those with maxillofacial injury without brain injury can be drawn only in a prospective study consisting of these two groups of patients. In our opinion, such a study is mandatory.

Protective value of helmet in MVA. In view of the overall cost of care to the society, emphasis should be placed on the prevention of road trafﬁc accidents. Although helmets provide significant protection against brain injury, they are less useful against fractures of the mandible, as the chin area is not protected.50,51 Further, many helmets appear on visual inspection to be standard helmets, they often lack the energy-absorption layer that can protect a rider from injury in the event of an accident. The prevalence of bicycle helmet use remains low despite research indicating the high level of head injury risk when bicycling without a helmet and the significant protection afforded by bicycle helmets. Several studies investigated the reasons of riders not wearing helmets. They demonstrated that the most common reason for not wearing a helmet were "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one."52 In several countries wearing of a bicycle helmet is mandatory. On the other hand other countries in which it is not mandatory to wear a helmet hide behind the fact that probably legal obligation will result in reduced cycling, concequently leading to reduced physical activity. Several authors however, demonstrated that there is limited evidence of reduced cycling if wearing of helmets is mandatory. They propose obligations should be coupled with physical activity promotion.

118 ͳͳͺ Conclusion Since oral and maxillofacial injuries are associated with functional, socioeconomic, and psychological factors, it is important to take appropriate preventative measures. Despite the retrospective nature of the present thesis the data may represent another important contribution in our increasing understanding of different accident related facial injuries and their consequences. This can be crucial for the adoption of new methods for preventing injuries, thus decreasing the associated socioeconomic costs of these individuals. Injury severity assessment tests could be helpful as prognostic modalities in predicting short term and long term consequences of the injury as both MVA and sport related accidents can result in brain injury. Studies about safety equipment and their protective effect against MVA and sport related facial injuries are needed. Further, legislations making the use of these safety equipment’s mandatory could be crucial to reduce the incidence of facial injuries in these categories.

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34. Maladière E, Bado F, Meningaud JP, Guilbert F, Bertrand JC. Aetiology and incidence of facial fractures sustained during sports: a prospective study of 140 patients. Int J Oral Maxillofac Surg 2001;30(4):291–295.

35. Mourouzis C, Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg. 2005;34(6):635–638.

36. Antoun JS, Lee KH. Sports-related maxillofacial fractures over an 11-year period. J Oral Maxillofac Surg 2008;66(3):504–508.

37. Roccia F, Diaspro A, Nasi A, Berrone S. Management of sport-related maxillofacial injuries. J Craniofac Surg 2008;19(2):377–782. 38. Murphy C, O'Connell JE, Kearns G, Stassen L. Sports-Related Maxillofacial Injuries. J Craniofac Surg 2015;26(7):2120–2123. 39. Hwang K, You SH, Lee HS. Outcome analysis of sports-related multiple facial fractures. J Craniofac Surg 2009;20(3):825–829. 40. Ruslin M, Boffano P, ten Brincke YJ, Forouzanfar T, Brand HS. Sport-related maxillo-facial fractures. J Craniofac Surg 2016;27(1): e91–e94.

41. Hayes RL. Biochemical markers of brain injury: applications to combat casualty care. Paper presented at: the RTO HFM Symposium on combat casualty care in ground based tactical situations: Trauma technology and emergency medical procedures; August 16–18, 2004;16–8; St. Pete Beach, USA

42. Pineda JA, Wang KK, Hayes RL. Biomarkers of proteolytic damage following traumatic brain injury. Brain Pathol 2004;14(2):202– 209.

43. Wu YC, Zhao YB, Lu CZ, Qiao J, Tan YJ. Correlation between serum level of neuron-specific enolase and long-term functional outcome after acute cerebral infarction: prospective study. Hong Kong Med J. 2004;10:251–254.

44. Wang KK, Ottens AK, Liu MC, Lewis SB, Meegan C, Oli MW, Tortella FC, Hayes RL. Proteomic identification of biomarkers of traumatic brain injury. Expert Rev Proteomics 2005;2(4):603–614.

45. Laterza OF, Modur VR, Crimmins DL, Olander JV, Landt Y, Lee JM, Ladenson JH. Identification of novel brain biomarkers. Clin Chem. 2006;52(9):1713–1721.

46. Zhang J, Zhang Y, El-Maaytah M, Ma L, Liu L, Zhou LD. Maxillofacial Injury Severity Score: proposal of a new scoring system. Int J Oral Maxillofac Surg 2006;35(2):109–114.

47. Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64(3):408–414. 11 48. Chen C, Zhang Y, An J-G, He Y, Gong X, Comparative study of four maxillofacial trauma scoring systems and expert score. J Oral Maxillofac Surg 2014;72(11):2212–2220.

49. Richter M, Otte D, Lehmann U, Chinn B, Schuller E, Doyle D, Sturrock K, Krettek C. Head injury mechanisms in helmet-protected motorcyclists: prospective multicenter study. J Trauma 2001;51(5):949–958. 50. Thompson DC, Nunn ME, Thompson RS, Rivara FP. Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA 1996;276(24):1974–1975. 51. Lee JH, Cho BK, Park WJ. A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg 2010;38(3):192– 196. 52. Conrad P, Bradshaw YS, Lamsudin R, Kasniyah N, Costello C. Helmets, injuries and cultural definitions: motorcycle injury in urban Indonesia. Accid Anal Prev 1996;28(2):193–200.

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ͳʹͳ 122

Chapter 12

Samenvatting

ͳʹ͵ Hoofdstuk 2: Maxillofaciale fracturen geassocieerd met auto- ongelukken: een overzicht van de recente literatuur.

De afgelopen dertig jaar zijn alle onderzoeken die zijn gepubliceerd over de verspreiding en karakteristieken van aan auto-ongeluk-gerelateerd letsel aan het gelaat systematisch beoordeeld. Het percentage auto-ongelukken als etiologische factor in epidemiologische onderzoeken over maxillofaciaal letsel varieert tussen de 11% en 85%. Over het geheel genomen werd een progressieve afname geconstateerd, met name in Noord-Amerika, Brazilië en Europa. In recente publicaties is eenvoudig een groot verschil op te merken in de incidentie van aan auto-ongelukken gerelateerde gelaatsfracturen in ontwikkelde landen (20% in Japan, 35,2 % in Nederland, 11% in Ierland) en ontwikkelingslanden (72-85% in India, 46,6 % in China). Natuurlijk kunnen deze data niet echt vergeleken worden vanwege de verschillen in wet- en regelgeving en implementatie daarvan.

Uit onderzoeken over het dragen van een helm door motorrijders in stedelijke gebieden kwamen als twee belangrijkste punten naar voren: de effectiviteit van wetten gericht op het gebruik van de helm en de bescherming die deze biedt tegen hersenbeschadiging en overlijden. Wetgeving die het gebruik van een helm verplicht voor alle motorrijders, is cruciaal om de incidentie van faciaal letsel te verminderen. In eerdere artikelen hierover is aangetoond dat motorongelukken bij 100% van de patiënten ernstig traumatisch hersenletsel veroorzaakt, gevolgd door bromfiets/scooter ongelukken (63,3%). Dit kan een gevolg zijn van de hoge snelheid die motoren kunnen bereiken in samenhang met het ongemak van het dragen van een helm, hetgeen ze kwetsbaarder maakt in het verkeer.

Hoofdstuk 3: Auto-ongelukken gerelateerd aan maxillofaciaal letsel: een Europees multicenter en prospectief onderzoek.

In dit onderzoek worden de demografische ontwikkeling en patronen van door auto-ongelukken gerelateerde maxillofaciale fracturen beoordeeld en besproken. Van de 3260 patiënten die binnen de onderzoeksperiode zijn opgenomen met maxillofaciale fracturen waren 326 trauma’s aan auto- ongelukken toe te schrijven, met een man-vrouw verhouding van 2,2:1. De hoogste incidentie (18%) werd in Zagreb (Kroatië) gemeten en het laagste aantal (0%) in Bergen (Noorwegen). Ongelukken met auto’s kwamen met 177 gevallen het meest voor, gevolgd door motorrijders. De

124 ͳʹͶ mandibulaire fractuur werd met 199 gevallen het meest waargenomen, gevolgd door de orbitaal- zygoma-fracturen (MZO). In alle drie de groepen waren mandibulaire- en MZO fracturen, met een paar variaties, de twee meest geziene fracturen. Het grote belang van volharding in het analyseren van alle facetten en bijzonderheden van auto-ongeluk gerelateerde faciale verwondingen moet worden benadrukt.

Hoofdstuk 4: Maxillofaciale fracturen geassocieerd met sportblessures: een overzicht van de hedendaagse literatuur.

Publicaties van de afgelopen twintig jaar over de wereldwijde verspreiding en karakteristieken van aan sport gerelateerde faciale verwondingen zijn bestudeerd en besproken. Uit deze evaluatie kwam naar voren dat het percentage van sport als etiologische factor voor faciale fracturen hoger lag in Europa en Oceanië. Er kwamen meer sportblessures voor bij mannen dan bij vrouwen. Verreweg de meeste ongevallen deden zich voor bij voetbal, met sommige uitzonderingen, veroorzaakt door lokale verschillen in sport, zoals rugby in Nieuw-Zeeland. In de meeste onderzoeken bleken het mandibulaire en het zygomatic-maxillaire complex de meest voorkomende verwonding. Verdere multicenter onderzoeken met de nadruk op preventieve maatregelen en lange-termijn observaties zijn noodzakelijk om hun doeltreffendheid aan te tonen in zake de preventie van maxillofaciale verwondingen.

Hoofdstuk 5: Sportgerelateerde maxillofaciale fracturen.

Het huidige onderzoek bevat data van 108 patiënten met 128 maxillofaciale fracturen. Het bevestigt de uitkomst van eerdere onderzoeken dat sport een majeure oorzaak is van maxillofaciale verwondingen. De meest voorkomende sport gerelateerde fracturen waren zygoma fracturen, gevolgd door mandibulaire fracturen. Dit komt overeen met uitkomsten van eerder gedane studies. Het is ook in lijn met het grote aantal mensen dat voetbalt in Nederland. Een interessante observatie in het onderhavige onderzoek is dat fracturen van de processus coronoideus alleen werden gezien bij voetballers en niet bij andere sporters. Mandibulaire fracturen werden relatief vaker gezien bij rugby dan bij andere sporten. De resultaten van dit onderzoek zijn overwegend vergelijkbaar met andere onderzoeken, waarmee deze data nuttig kunnen zijn voor de ontwikkeling van protocollen teneinde maxillofaciale fracturen te voorkomen bij bepaalde sporten. 1212 125 ͳʹͷ Hoofdstuk 6: Aan sport gerelateerde maxillofaciale fracturen: een multicenter en prospectief onderzoek.

In een multicenter onderzoek werd de demografische ontwikkeling en patronen van aan sport gerelateerde maxillo-faciale fracturen onderzocht. Van de 3260 patienten die werden opgenomen met maxillofaciale verwondingen gedurende de onderzoeksperiode waren 275 traumata toe te schrijven aan sportongelukken met een man-vrouw verhouding van 4,1:1. Voetbal was meestal de oorzaak voor maxillofaciale fracturen (33%), gevolgd door rugby (18%) en skiën (12%). De meest voorkomende fractuur wet gezien in onderkaak met 116 fracturen, gevolgd door maxillo zygomatic orbital fracturen. Er blijken echter nog steeds teveel variabelen te zijn om conclusies te trekken voor wat betreft aan sport gerelateerd letsel, omdat bij iedere sport afzonderlijk verschillende mechanismen voor wat betreft letsel, diffusie, en preventieve middelen worden gehanteerd.

Hoofdstuk 7: Gebitstrauma in combinatie met maxillofaciale fracturen; een epidemiologisch onderzoek.

Alle patiënten met faciaal trauma gepaard aan letsel aan het gebit werden gezien aan het VU Medisch Centrum (VUmc) in Amsterdam. Van in totaal 707 patiënten hadden 164 patiënten (23,2%) letsel aan het gebit gepaard aan faciale fracturen. In dit onderzoek bleek dat een prevalentie van gebitsletsel samen met faciale fracturen hoger uitviel dan in vorige onderzoeken werd gevonden (41,8%). Le Fort fracturen en condylaire, parasymphysis fracturen van de onderkaak kwamen significant vaker voor in combinatie met gebitsletsel. De combinatie van gebitsletsel met zygoma fracturen was significant minder. Voorts bleek uit ons onderzoek dat het onderste deel van het gezicht vatbaarder is voor fracturen dan de bovenste delen in zowel de groep met gebitsletsel als de groep zonder gebitsletsel. Een oorzaak van de hogere incidentie van faciale fracturen kan zijn dat de meeste patiënten in de regio Amsterdam behandeld worden als gevolg van fietsongelukken en niet door interpersoonlijk geweld. De maxilla toonde de hoogste incidentie van tandletsel. De gebits elementen, die het meest aangetast werden waren de boven tanden (maxillaire snijtanden) (33,1%), gevolgd door ondertanden (mandibulaire snijtanden) (13,6%), kiezen in onderkaak (molaren) (12,8%) en kiezen in de bovenkaak (premolaren) (12,6%). De resultaten uit dit onderzoek zijn grotendeels in lijn met andere onderzoeken in de literatuur.

126 ͳʹ͸

Hoofdstuk 8: De Maxillofacial Injury Severity Score (MFISS) en Facial Injury Severity Scale (FISS) als een voorspelling voor hersenletsel bij patiënten met een maxillofaciale fractuur

Dit onderzoek is gebaseerd op een analyse van een patiënten database van de afdeling Orale en Maxillofaciale Chirurgie van VUmc in Amsterdam. Tussen 2002 en 2013 werden 1326 patiënten behandeld in verband met maxillofaciale fracturen. Op het totaal aantal patiënten werden 52 patiënten met traumatisch hersenletsel (TBI) gediagnosticeerd. Twee algemeen gebruikte systemen werden geselecteerd: MFISS en FISS. Iedere patiënt kreeg aan de hand van deze systemen een score. De gemiddelde waarde van MFISS was 5,70, de gemiddelde waarde van FISS kwam op 2,25. Een auto ongeluk was de meest voorkomende oorzaak van TBI; dit kwam bij 22 patiënten voor (p < 0,05). De waarden van zowel FISS als MFISS werden statistisch geassocieerd met de aanwezigheid van TBI. Op basis van onze resultaten was de uitkomst dat FISS en MFISS nuttige en waardevolle onderzoeksmiddelen zijn voor het voorspellen van TBI. High-energy-trauma, zoals bij MVA (auto-ongeluk) dat gedetermineerd wordt door meervoudige en complexe faciale fracturen (hogere FISS en MFISS waarden) laat een hoger risico zien op associatie met hersenletsel. Volgens een recent onderzoek dat is gebaseerd op de Finite Element Analysis van maxillofaciaal trauma geassocieerd met TBI’s, speelt de locatie en de richting van het geweld een grote rol bij het vaststellen van de ernst van het hersenletsel. Dit onderzoek bevestigt dat er een hoge associatie tussen de afstand en de locatie van de botsing tot het brein bestaat. Met name de anterior-interior frontale kwab, vanwege de directe nabijheid tot de hersenen, levert aanzienlijk ernstiger letsel op.

Hoofdstuk 9: Het gebruik van neuron specifiek enolase (NSE) om licht hersenletsel te voorspellen bij patiënten die als gevolg van een motorongeluk maxilla- faciale fracturen hebben opgelopen: een pilot onderzoek.

Er werd bij 40 gezonde mensen (controle groep) bloed afgenomen en bij 48 trauma patiënten die geïsoleerde maxillofaciale fracturen hadden opgelopen waarbij door toepassing van de Glasgow Coma Scale lichte hersenschade was vastgesteld. In de traumagroep werden correlaties vastgesteld tussen de NSE serum waarden en verschillende faciale fracturen. De gemiddelde NSE 12 ͳʹ͹ 12 127 serum waarde binnen de groep van 48 patiënten die een maxillofaciale fractuur hadden doorgemaakt was 13,12 ng/ml. Deze waarden waren significant hoger dan de gemeten waarden binnen de gezonde controle groep. De gemiddelde NSE serum waarden in het lage gedeelte van het faciale skelet waren hoger dan de waarden in het bovenste faciale gedeelte. En de gemiddelde NSE waarden in het middelste en lagere gedeelte was met 11,97 ng/ml hoger dan van het middelste gedeelte. Voorts verschilden de NSE waarden van patiënten met faciale fracturen significant, afhankelijk van de locatie van de faciale fracturen. De laagste NSE waarden werden aangetroffen bij patiënten met fracturen in het middenfaciale gedeelte, wat impliceert dat de middenfaciale botstructuur beter in staat is om traumatische klappen op te vangen dan andere botstructuren waardoor het neurocranium beschermd wordt tegen ernstig trauma. Interessant is dat alle patiënten in ons onderzoek die klappen hadden doorgemaakt tegen hun onderkaak hogere NSE waarden hadden. De resultaten van dit onderzoek zijn overwegend vergelijkbaar met andere onderzoeken aangegeven dat faciale fracturen een hoger risico van hersenletsel markeren. Een verklaring voor de hogere NSE waarden bij patiënten die fracturen in de onderkaak hebben doorstaan, zou kunnen zijn door de directe energie transmissie naar de schedelbasis en de hersenen. Door de botsing met de onderkaak worden krachten overgedragen door de condylus naar het slaapbeen, vandaar naar de schedelbasis, mogelijk leidend tot een toename van de NSE serumwaarden.

Hoofdstuk 10: De invloed van helm op de preventie van maxillofaciale fracturen bij motorongelukken

Het doel van dit onderzoek was om uit te vinden of helmgebruik bij motorongelukken leidt tot een vermindering van letsel bij botsingen met het hoofd. Het verschil in NSE serumwaarden bij patiënten met helm en zonder helm met maxillofaciale fracturen na een motorongeluk werd ook onderzocht. In totaal 48 personen (22 met helm en 26 zonder helm) met maxillofaciale fracturen werden onderverdeeld in drie gebieden: boven-, midden- en onder gezicht. Alle patiënten werden na aankomst in het ziekenhuis kregen een score door toepassing van de Glasgow Coma Scale. Het meest prevalente gebied van de maxillofaciale fractuur bij de gehelmde groep was het midden gezicht (40,9%) en bij de ongehelmde groep was het boven-midden-onder gezicht (26,9%). Er was geen significant verschil tussen de NSE serumwaarden van de gehelmde groep (11,5 mg.nl) en die van de groep zonder helm (14,49 ng/ml) (p>0,05). Desalniettemin hadden de half gehelmden in dit onderzoek lagere NSE waarden dan de groep zonder helm. Deze uitkomst laat zien dat half gehelmden beter beschermd zijn tegen hersenletsel dan mensen zonder helm.

128 ͳʹͺ 129 130

Acknowledgements

ͳ͵ͳ

Al-ḥamdu li-llāhi rabbi l-ʿālamīn, all the praises and thanks to Allah Subḥānahu wa ta'alā, the Lord of the universes. Today is the day of finishing my thesis after an intensive learning. Writing this thesis has given a big impact on me. I would never have been able to finish my thesis without the guidance of colleagues, help from friends, and support from my family. Here, I would like to reflect on the people who have generously contributed to the work presented in this thesis.

Foremost, I would like to express my sincere gratitude to my promotor, Prof. dr. Tymour Forouzanfar for the continuous support of my Ph.D study. I am particularly indebted to have you as my promotor. Thank you so much for encouraging my research and for allowing me to grow as a research scientist. Your enthusiasm, trust, enormous support, and motivation on finishing my study are infinite. I have been extremely lucky to have a supervisor who cared so much about my work.

Special mention goes to my enthusiastic co-promotor Prof. dr. D.B. (Bram) Tuinzing, thank you very much for your brilliant comments and critical suggestions. You really gave me the strength to keep on going and finishing my study. My Ph.D has been an amazing experience, not only because your tremendous academic support, but also for giving me lots of wonderful opportunities on scientific matters which improve my thesis so much, also for giving me lots of wonderful opportunities on clinical matters which improved my proficiency. You have been there to support me not only as my mentor, but really as my family here in the Netherlands.

Similar, profound gratitude to my co-promotor dr. Paolo Boffano, thank you very much for your whole heartedly for an enormous contribution to my study. You have always welcomed me to discuss my research, helped me to develope new ideas, and responded to my questions and queries so promptly. Hard times became so much easier with you always being around. You are all such God’s blessing. The three of you guided me with unconditional supports to strive toward my goals. It has been a great honor for me to do this Ph.D under your supervision.

Besides my advisor, I would like to thank the members of my doctoral committee, Prof. dr. D. Wismeijer, Prof. dr. E.A.J.M. Schulten, Prof. dr. B.J. van Royen, Prof. Dr. drg. Y.Y. Harmas, dr. E.M. van Cann, for reviewing this thesis, for their insightful comments, and for the willingness to join the committee.

I would like to thank people from the Department of Oral and Maxillofacial Surgery/Oral Pathology VUmc, Prof. dr. I. van der Waal, Prof. dr. E.A.J.M. Schulten, K.H. Karaqozoglu, dr. M.N. Helder, M.S Maningky, B.A. Meijer, Prof. dr. J.G.A.M. de Visscher, M.Gilijamse, dr. A. Ridwan Pramana, ͳ͵ʹ who made me feel welcome, and also special thank to dr. Martijn van Steenbergen, this study would have not finished without the enormous help from all of you. I would also like to thank Annelies van de Geest and all the members of staff administration and to all the other committed people at the Department of Oral and Maxillofacial Surgery/Oral Pathology VUmc in Amsterdam. 132 My VUmc Ph.D colleagues, Dessy Rachmawati, Diandra Sabrina N. Kalla & Family, Faqi Nurdiansyah Hendra & Family, Rifaat Nurrahma, Hasanuddin, Aisha A. Hussein, Salem Al Kaabi, thanks for the collaboration. You were not only my colleagues, but also a good friends during my time here. My thoughts are also going to all other Indonesian best friends in The Netherlands, Abbas Makkassau & Oktiva Dwi Prihatin, Dijo Amin & Fatimah Dijo, Daniel & Family, Ronny Anthonijz & Family, L.C. Tse, M. Wijono & Family, Sunarti Heersink Tutu & Family, thank you for the lovely friendship and also for joining together, to keep us close to our roots. Also to the Indonesian students group in the Netherlands, Firdaus Hamid, Andi Rofian Sultan, Andi Ahmad Yani & Family, Andriany Qanitha & Family, Aldian Irma Amaruddin & Family, Amalia Mulia Utami & Family, Nurul Qalby & Family, Nur Isdah Idris & Family, thank you for all your support and friendship. Thanks to all of you, for your loving companionship in the Netherlands. Thank you prof. A Jan Passchier, you always gathered Indonesian students together, and also always listened to us and were there when we needed any help.

To all my colleagues, Charlotte R.A. Verlinden, Manon Weijers, Wilhelmus J.J.M. Martin, it was my pleasure to work with you on cleft charity journey together in Makassar, Indonesia, Dear Rtn. Manon thanks for your support with your Rotary Club Alkmaar together with Rotary Club Ujangpandang for supported the schisis Project at South Celebes. I am as Rotarian now with new Rotary Club Makassar City Center, always be the inspiration.

Also two colleagues, Jill Knips (Germany), Laura Gabriela Gonzalez Valdez (Mexico), it was my pleasure to work with you on cleft charity journey together to advancement of skills and science of oral and maxillofacial surgery, during your fellowship of the International Association of Oral and Maxillofacial Surgeons (IAOMS) in cleft lip, and palate craniofacial surgery in Makassar, Indonesia.

ͳ͵͵ I would like to thank people from the Department of Oral and Maxillofacial Surgery/Oral Pathology VUmc, Prof. dr. I. van der Waal, Prof. dr. E.A.J.M. Schulten, K.H. Karaqozoglu, dr. M.N. Helder, M.S Maningky, B.A. Meijer, Prof. dr. J.G.A.M. de Visscher, M.Gilijamse, dr. A. Ridwan Pramana, who made me feel welcome, and also special thank to dr. Martijn van Steenbergen, this study would have not finished without the enormous help from all of you. I would also like to thank Annelies van de Geest and all the members of staff administration and to all the other committed people at the Department of Oral and Maxillofacial Surgery/Oral Pathology VUmc in Amsterdam.

My VUmc Ph.D colleagues, Dessy Rachmawati, Diandra Sabrina N. Kalla & Family, Faqi Nurdiansyah Hendra & Family, Rifaat Nurrahma, Hasanuddin, Aisha A. Hussein, Salem Al Kaabi, thanks for the collaboration. You were not only my colleagues, but also a good friends during my time here. My thoughts are also going to all other Indonesian best friends in The Netherlands, Abbas Makkassau & Oktiva Dwi Prihatin, Dijo Amin & Fatimah Dijo, Daniel & Family, Ronny Anthonijz & Family, L.C. Tse, M. Wijono & Family, Sunarti Heersink Tutu & Family, thank you for the lovely friendship and also for joining together, to keep us close to our roots. Also to the Indonesian students group in the Netherlands, Firdaus Hamid, Andi Rofian Sultan, Andi Ahmad Yani & Family, Andriany Qanitha & Family, Aldian Irma Amaruddin & Family, Amalia Mulia Utami & Family, Nurul Qalby & Family, Nur Isdah Idris & Family, thank you for all your support and friendship. Thanks to all of you, for your loving companionship in the Netherlands. Thank you prof. A Jan Passchier, you always gathered Indonesian students together, and also always listened to us and were there when we needed any help.

To all my colleagues, Charlotte R.A. Verlinden, Manon Weijers, Wilhelmus J.J.M. Martin, it was my pleasure to work with you on cleft charity journey together in Makassar, Indonesia, Dear Rtn. Manon thanks for your support with your Rotary Club Alkmaar together with Rotary Club A Ujangpandang for supported the schisis Project at South Celebes. I am as Rotarian now with new Rotary Club Makassar City Center, always be the inspiration.

To all my Dutch students research-internship in my Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Hasanuddin University, Makassar, Indonesia, Lawrence S. Dom, Amanda M. Scholtes, David Hardjosantoso, Arian Vojdani, Eveline Konijnendijk, K. Joanna Li, Shanice van Stenus, Kiara N. van Trikt, (all from VUmc-ACTA, Amsterdam), and also to Dagmar E. Wortmann (University of Groningen), Lara S. van de Lande (Erasmus University Rotterdam), Munifa Amira Anthonijz (The Hague University of Applied Sciences), it was my pleasure to work with you. Frida Tjiook-Tan & Yang Tjiook, thank you for all your support and also with your Soroptimistͳ͵͵ International Club Amsterdam Amstel for supporting the Schisis Project Celebes Ceft Center at Makassar. Here also I would like to express the deepest appreciation to the Prof. Dr. Dwia Aries Tina Pulubuhu, MA., Rector of Hasanuddin University, and also to Prof. Dr. Ir. Muh. Restu, MP., Prof. Dr. Ir. Sumbangan Baja, M.Sc., Prof. Dr. drg. A. Arsunan, M.Kes, vice Rector of Hasanuddin133 University, and also thanks to Prof. Dr. dr. Idrus A. Paturusi, SpB., Sp.OT.(K), Prof. Dr. Eng. Dadang Ahmad Suriamihardja, M.Eng., and, Prof. Dr. dr. A. Wardihan Sinrang, MS., former Rector and former vice Rector of Hasanuddin University, who have been giving me a great support for my study. Thanks to the Ministry of Research, Technology and Higher Education of the Republic of Indonesia, for their scholarship for overseas.

Thanks to Prof. Makoto Noguchi, DDS., Ph.D., Prof. Keng-Liang Ou, Ph.D., Prof. Lun Jou Lo, MD., thanks to you all, for giving me lots of wonderful opportunities on clinical and scientific matters which can improved my proficiency and special thank to Prof. dr. Chairuddin Rasyad, Ph.D., Sp.B., Sp.OT.(K)., drg. Hj. Halimah Dg. Sikati, Prof. drg. Tet Soeparwadi, Sp.BM.(K) (late), Prof. dr. A. Husni Tanra, Ph.D., Sp.An.(K)., and Prof. Dr. drg. Eky Soeria Soemantri, Sp.Ort.(K)., Dr. dr. Warsinggih, Sp.B-KBD., who always supported me from the very beginning. You helped and inspired me to find a way to achieve my passion to study abroad. I am very grateful to have you in my life.

Then, for the Faculty of Dentistry, Hasanuddin University, I would like to thank to Prof. drg. H.M. Hatta Hasan S., Ph.D., Sp.BM., Prof. drg. Mansjur Nasir, Ph.D., Prof. Dr. drg. Burhanuddin Dg. Pasiga, M.Kes., Prof. Dr. drg. Sumintarti, MS., Prof. Dr. drg. Hasanuddin, MS., Prof. Dr. drg. Rasmidar Samad, MS., Prof. Dr. drg. Harlina, M.Kes., Prof. Dr. drg. M. Hendra Chandha, MS., Prof. drg. M. Dharmautama, Ph.D., Sp.Pros.(K)., Prof. Dr. drg. Sri Oktawati, Sp.Perio.(K)., Prof. Dr. drg. Sherly Horax, MS., Prof. Dr. drg. Barunawaty Yunus, M.Kes., Sp.RKG.(K)., Prof. Dr. drg. Bahruddin Thalib, M.Kes., Sp.Pros., Prof. Dr. drg. Edy Machmud, Sp.Pros.(K)., Prof. Dr. drg. Fajriani, M.Si., and also to all my seniors, best friends thanks to you all, for your enormous support when I needed a hand, even though I was so far away. Thanks to all my colleagues in the Department of Oral and Maxillofacial Surgery, Prof. drg. H.M. Hatta Hasan S., Ph.D., Sp.BM., Prof. Dr. drg. M. Hendra Chandha, MS., drg. Netty N. Kawulusan, M.Kes., drg. Surijana Mappangara, M.Kes., Sp.Perio., drg. Nasman Nuralim, Ph.D., (late), drg. Hasmawati Hasan, M.Kes., drg. Andi Tajrin, M.Kes., Sp.BM.(K)., drg. Abul Fauzi, Sp.BM., drg. M. Irfan Rasul, Sp.BM, and also I would like to express the deepest appreciation to the Dean of Faculty of Dentistry, Hasanuddin

ͳ͵Ͷ (University of Groningen), Lara S. van de Lande (Erasmus University Rotterdam), Munifa Amira Anthonijz (The Hague University of Applied Sciences), it was my pleasure to work with you. Frida Tjiook-Tan & Yang Tjiook, thank you for all your support and also with your Soroptimist International Club Amsterdam Amstel for supporting the Schisis Project Celebes Ceft Center at Makassar. Here also I would like to express the deepest appreciation to the Prof. Dr. Dwia Aries Tina Pulubuhu, MA., Rector of Hasanuddin University, and also to Prof. Dr. Ir. Muh. Restu, MP., Prof. Dr. Ir. Sumbangan Baja, M.Sc., Prof. Dr. drg. A. Arsunan, M.Kes, vice Rector of Hasanuddin University, and also thanks to Prof. Dr. dr. Idrus A. Paturusi, SpB., Sp.OT.(K), Prof. Dr. Eng. Dadang Ahmad Suriamihardja, M.Eng., and, Prof. Dr. dr. A. Wardihan Sinrang, MS., former Rector and former vice Rector of Hasanuddin University, who have been giving me a great support for my study. Thanks to the Ministry of Research, Technology and Higher Education of the Republic of Indonesia, for their scholarship for overseas.

I would like to extend my sincere thanks to the colleagues vice directors of the Dental Hospital Hasanuddin University, drg. Andi Tajrin, M.Kes., SpBM.(K)., drg. Adam Malik Hamudeng, 134M.MedEd., drg. Surijana Mappangara, M.Kes., SpPerio., and Dr. drg. Aries Chandra Trilaksana, Sp.KG.(K), for keeping in touch and sharing the ups and downs in life, and all staf members of the Dental Hospital Hasanuddin University.

My special thank also to my mentors in Indonesia, Prof. drg. Sunardi Mangundjaja, Sp.BM.(K) (Padjadjaran University, Bandung), Prof. Dr. drg. Benny Sjariefsyah Latief, Sp.BM.(K) (University of Indonesia, Jakarta), Prof. drg. R.M. Coen Pramono Danudiningrat, SU., Sp.BM.(K) (Airlangga University, Surabaya), Prof. drg. Iwan Tofani, Ph.D., Sp.BM (University of Indonesia, Jakarta), Prof. Dr. drg. Harmas Yazid Yusuf, Sp.BM.(K) (Padjadjaran University, Bandung), and drg. M. Masykur Rahmat, Sp.BM.(K) (late) (Gadjah Mada University, Yogyakarta), for always support and encourage me to improved my proficiency. Also to my paranymphs, Diandra Sabrina Natsir Kalla A and Faqi Nurdiansyah Hendra, thanks for helping me on the thesis defense preparation. Best of luck for you Ph.D.

Last, but most importantly, my deepest gratitude and regards to my mother for her continued support and encouragement. She continually amazed me for supporting me spiritually throughout my life. I can see myself completing this highest educational qualification because of your teaching in my life and your blessings, and very much treasure the loves of my life. My special thanks to my dear wife Nilla Mayasari, I thank you for your unconditional love, patience, understanding, and support, it was sometimes really hard to be on such a distance, where would I be without you, giving me spirit and unconditional love. My daughter Naila Nursyifa Ruslin and my son Nabil Syafi Ruslin, thank to you for being part of this journey and for embracing the joys, excitements, and desperations of this venture. I dedicate this thesis to all of you. Many thanks to my mother in law, and to my brothers and sister, also to my brothers in law, for your encouragement and support.

It is not possible to mention all the names here but there any many more colleagues, friends, and family whom I wish to offer my gratitude for their help, encouragement, and nice memories during to finish this thesis.

ͳ͵ͷ University, Prof. Dr. drg. Bahruddin Thalib, M.Kes., Sp.Pros, and also all former Dean of Faculty of Dentistry, Hasanuddin University, drg. Hj. Halimah Dg. Sikati, Prof. drg. H.M. Hatta Hasan S., Ph.D., Sp.BM., drg. M. Amin Kansi, MS., Ph.D., Prof. drg. Moh. Dharmautama, Ph.D., Sp.Pros.(K), and Prof. drg. Mansjur Nasir, Ph.D., for always support and encourage me to obtain this Ph.D.

I would like to extend my sincere thanks to the colleagues vice directors of the Dental Hospital Hasanuddin University, drg. Andi Tajrin, M.Kes., SpBM.(K)., drg. Adam Malik Hamudeng, M.MedEd., drg. Surijana Mappangara, M.Kes., SpPerio., and Dr. drg. Aries Chandra Trilaksana, Sp.KG.(K), for keeping in touch and sharing the ups and downs in life, and all staf members of the Dental Hospital Hasanuddin University.

Last, but most importantly, my deepest gratitude and regards to my mother for her continued support and encouragement. She continually amazed me for supporting me spiritually throughout my life. I can see myself completing this highest educational qualification because of your teaching in my life and your blessings, and very much treasure the loves of my life. My special thanks to my A dear wife Nilla Mayasari, I thank you for your unconditional love, patience, understanding, and support, it was sometimes really hard to be on such a distance, where would I be without you, giving me spirit and unconditional love. My daughter Naila Nursyifa Ruslin and my son Nabil Syafi Ruslin, thank to you for being part of this journey and for embracing the joys, excitements, and desperations of this venture. I dedicate this thesis to all of you. Many thanks to my mother in law, and to my brothers and sister, also to my brothers in law, for your encouragement and support.

ͳ͵ͷ

135 136

List of publications

ͳ͵͹ Published 1. The anthropological aspects of dentofacial deformities: A comparison between Indonesian and Dutch cohorts. Muhammad Ruslin, Tymour Forouzanfar, Ida A. Astuti, Eky S. Soemantri, Dirk B. Tuinzing Journal of Dentomaxillofacial Science 2014 Feb;13(1):48–54.

2. Dental trauma in association with maxillofacial fractures; An epidemiological study. Muhammad Ruslin, Jan Wolff, Henk S. Brand, Paolo Boffano, Tymour Forouzanfar Dental Traumatology 2015 April;31(4):318–323.

3. Maxillofacial fractures associated with motor vehicle accidents: A review of the current literature. Muhammad Ruslin, Jan Wolff, Tymour Forouzanfar, Paolo Boffano Journal Oral and Maxillofacial Surgery, Medicine, and Pathology 2015 May;27(3):303–307.

4. The epidemiology, treatment, and complication of dentofacial deformities in an Indonesian population: A 21-year analysis. Muhammad Ruslin, Tymour Forouzanfar, Ida A. Astuti, Eky S. Soemantri, Dirk B. Tuinzing Journal Oral and Maxillofacial Surgery, Medicine, and Pathology 2015 Sep;27(5):601–607.

5. Effect of nanostructured thin film on minimally invasive surgery devices applications: Characterization, cell cytotoxicity evaluation and an animal study in rat. Keng-Liang Ou, Chao-Chia Weng, Erwan Sugiatno, Muhammad Ruslin, Yun-Ho Lin, Han-Yi Cheng Surgical Endoscopy 2015 Nov:30(7);3035–3049.

6. Sport related maxillo-facial fractures. Muhammad Ruslin, Paolo Boffano, Y.J.D. ten Brincke, Tymour Forouzanfar, Henk S. Brand Journal of Craniofacial Surgery 2016 Jan;27(1):e91–e94.

7. Assessing the need for a protocol in monitoring weight loss and nutritional status in orthognathic surgery based on patients experiences. Muhammad Ruslin, Hannah Dekker, Dirk B. Tuinzing, Tymour Forouzanfar Journal of Clinical and Experimental Dentistry 2017 Feb;9(2):e272–e275.

8. Micro/nanostructured surface modification using femtosecond laser pulses on minimally invasive electrosurgical devices. Chia-Cheng Lin, Hao-Jan Lin, Yun-Ho Lin, Erwan Sugiatno, Muhammad Ruslin, Chen-Yao Su, Keng-Liang Ou, Han-Yi Cheng Journal of Biomedical Materials Researc Part B Applied Biomaterials 2017 May;105(4):865– 873.

9. An innovative a–calcium sulfate hemihydrate bioceramic as a potential bone graft substitute. Heng-Jui Hsu, Rahmat Abd Waris, Muhammad Ruslin, Yun-Ho Lin, Chin-Sung Chen, Keng- Liang Ou Journal of the American Ceramic Society 2017 August;101(1):419–427.

10. The difference uses of panoramic photo and CBCT evaluation of the gnathoplasty surgery outcome. Ayu Wahyuni, Muliaty Yunus, Muhammad Ruslin Journal of Dentomaxillofacial Science 2017 August;2(2):110–113.

138 ͳ͵ͺ 11. The application of silver nano-particles on developing potential treatment for chronic rhinosinusitis: Antibacterial action and cytotoxivity effect on human nasal epithelial cell model. Hsin-Hua Chou, Min-Tsan Huang, Sylvia L.F. Pender, Muhammad Ruslin, Yun-Ho Lin, Keng- Liang Ou Materials Science & Engineering C Materials for Biological Applications 2017 Nov;80:624–630.

12. 3D assessment of damaged bicycle helmets and corresponding craniomaxillo mandibular skull injuries: A feasibility study. Gustaaf J.C. van Baar, Muhammad Ruslin, Maureen van Eijnatten, George K. Sandor, Tymour Forouzanfar, Jan Wolff Injury, 2017 Des:48(12):2872–2878.

13. The epidemiology, treatment, and complication of ameloblastoma in East-Indonesia : 6 Years Retrospective Study. Muhammad Ruslin, Faqi N. Hendra, Arian Vojdani, David Hardjosantoso, Mohammad Gazali, Andi Tajrin, Jan Wolff, Tymour Forouzanfar Medicina Oral Patologia Oral y Cirugia Bucal 2018 Jan;23(1):e58–e58.

14. Hybrid micro/nanostructural surface offering improved stress distribution and enhanced osseointegration properties of the biomedical titanium implant. Ping-Jen Hou, Keng-Liang Ou, Chin-Chieh Wang, Chiung-Fang Huang, Muhammad Ruslin, Erwan Sugiatno, Tzu-Sen Yang, Hsin-Hua Chou Journal of the Mechanical Behavior of Biomedical Materials 2018 Mar;79:173–180.

15. The potential of the stem cells composite hydrogel wound dressings for promoting wound healing and skin regeneration: In vitro and in vivo evaluation. Ling-Chuan Hsu, Bou-Yue Peng, May-Show Chen, Bahruddin Thalib, Muhammad Ruslin, Tran Dang Xuan Tung, Hsin-Hua Chou, Keng-Liang Ou P Journal of Biomedical Materials Researc Part B Applied Biomaterials Mar 2018. Epub ahead of print. P

16. Long exposure of argon plasma coagulation induces more thermal damage accompanied by a higher expression of NF-kB and caspase-3. Rahmat A. Waris, Keng-Liang Ou, Muhammad Ruslin, Bahruddin Thalib, Chung-Ming Liu, Hsin-Hua Chou Journal of Dentomaxillofacial Science 2018 April;3(1):62–69.

17. Total tannin levels analysis of brown algae (sargassum sp. and padina sp.) to prevent blood loss in surgery. Abul Fauzi, Satriani Lamma, Muhammad Ruslin Journal of Dentomaxillofacial Science 2018 April;3(1):37–40.

18. Utilization of pedicled buccal fat pads for coverage of the lateral relaxing wound: A review of literature and a case series of 15 patients. Muhammad Ruslin, Andi S. Hajrah Yusuf, Andi Tajrin, Lun-Jou Lo, Tymour Forouzanfar Journal of Clinical and Experimental Dentistry 2018 May;10(5):e502–506.

19. Evaluation of surface characteristics and hemocompatibility on the of the oxygen plasma- modified biomedical titanium. Hsi-Jen Chiang, Hsin-Hua Chou, Keng-Liang Ou, Erwan Sugiatno, Muhammad Ruslin, Rahmat Abd Waris, Chiung-Fang Huang, Chung-Ming Liu, Pei-Wen Peng Metals 2018 July;8(7):513.

139ͳ͵ͻ 20. Analysis of total flavonoid levels in brown algae (Sargassum sp. and Padina sp.) as analgesic drug therapy. Muhammad Ruslin, Akbar Fuad Husain, Hajrah Yusuf AS, Subehan Asian Journal of Pharmaceutical and Clinical Research 2018 July;11(7):81–83.

Accepted for publication

21. Motor-vehicle accidents related maxillofacial injuries: A multicenter and prospective study. Muhammad Ruslin, Matteo Brucoli, Paolo Boffano, Arnaldo Benech, Jan Wolff, Emil Dediol, Vedran Uglešić, Žiga Kovačič, Aleš Vesnaver, Vitomir S. Konstantinović, Milan Petrović, Jonny Stephens, Amar Kanzaria, Nabeel Bhatti, Simon Holmes, Petia F. Pechalova, Angel G. Bakardjiev, Vladislav A. Malanchuk, Andrey V. Kopchak, Pål Galteland, Even Mjøen, Per Skjelbred, Helios Bertin, F Marion, Julien Guiol, Pierre Corre, Sigbjørn Løes, Njål Lekven, Sean Laverick, Peter Gordon, Tiia Tamme, Stephanie Akermann, K Hakki Karagozoglu, Sofie C. Kommers, Jan G. de Visscher, Tymour Forouzanfar. Oral Surg Oral Med Oral Pathol Oral Radiol

22. The influence of helmet on the prevention of maxillofacial fractures sustained during motorcycle accidents. Muhammad Ruslin, Jan Wolff, Harmas Y. Yusuf, Muhammad Z. Arifin, Jan Wolff, Paolo Boffano, Tymour Forouzanfar Cogent Engineering

23. The use of neuron-specific enolase to predict brain injury in maxillofacial fractures after vehicle accidents: A pilot study. Muhammad Ruslin, Harmas Yazid Yusuf, Muhammad Zaifullah Arifin, Jan Wolff, Paolo Boffano, Tymour Forouzanfar Chinese Journal of Traumatology

24. Establishing cleft services in developing countries: complications of cleft lip and palate surgery in rural areas of Indonesia. Muhammad Ruslin, Lawrence Dom, Andi Tajrin, A.S. Hajrah Yusuf, Syafri K. Arif, Andi H. Tanra, Keng Liang Ou, Tymour Forouzanfar Archives of Plastic Surgery

Submitted

25. Rapid and efficient fabrication of the biocompatible bioceramic for bone graft substitute applications: Phase transformation, in vitro cytocompatibility and an in vivo study in the chick chorioallantoic membrane model. Keng-Liang Ou, Heng-Jui Hsu, Yun-Ho Lin, Muhammad Ruslin, Ching-Zong Wu, Rahmat A. Waris

26. Intraoperative and early postoperative complications using the buccal fat pad during cleft palate surgery in East Indonesia. Muhammad Ruslin, Diandra Sabrina N. Kalla, Andi S. Hajrah Yusuf, Andi Tajrin, Paolo Boffano, Tymour Forouzanfar

27. Maxillofacial fractures associated with sport injuries: A review of the current literature. Paolo Boffano, Muhammad Ruslin, Matteo Brucoli, Arnaldo Benech, Tymour Forouzanfar

140 ͳͶͲ 28. High-energy plasma modification induced phase transformation and variation of the surface properties on the nanostructured oxide layer of biomedical titanium implant. Hsi-Jen Chiang, Chung-Ming Liu, Keng-Liang Ou, Bahruddin Thalib, Rahmat Waris, Muhammad Ruslin, Chiung-Fang Huang

29. The Maxillofacial Injury Severity Score (MFISS) and Facial Injury Severity Scale (FISS) as a predictor brain injury with maxillofacial fractures patients. Muhammad Ruslin, Paolo Boffano, HCW de Vet, M Brucoli, KH Karagozoglu, Tymour Forouzanfar

30. A promising of nanostructured-gold surface offering improved thermomechanical and anti- adhesive properties of the electrosurgical electrode for biomedical applications. Hsi-Jen Chiang, Chung-Ming Liu, Bahruddin Thalib, Muhammad Ruslin, Keng-Liang Ou, Pei-Wen Peng, Chiung-Fang Huang

31. Surface characterization and thermomechanical behavior of nanostructured-gold layer for biomedical applications. Keng-Liang Ou, Chi-Ming Wu, Rahmat A Waris, Erwan Sugiatno, Muhammad Ruslin, Chung-Ming Liu, Hsin-Hua Chou

32. Sport related maxillofacial fractures: A multicenter and prospective study. Muhammad Ruslin, Matteo Brucoli, Paolo Boffano, Arnaldo Benech, Emil Dediol, Vedran Uglešić, Žiga Kovačič, Aleš Vesnaver, Vitomir S. Konstantinović, Milan Petrović, Jonny Stephens, Amar Kanzaria, Nabeel Bhatti, Simon Holmes, Petia F. Pechalova, Angel G. Bakardjiev, Vladislav A. Malanchuk, Andrey V. Kopchak, Pål Galteland, Even Mjøen, Per Skjelbred, Helios Bertin, Pierre Corre, Sigbjørn Løes, Njål Lekven, Sean Laverick, Peter Gordon, Tiia Tamme, Stephanie Akermann, K Hakki Karagozoglu, Sofie C. Kommers, Jan G. de Visscher, Tymour Forouzanfar P

33. Global incidence and profile of ameloblastoma: A systematic review and meta-analysis. P Faqi Nurdiansyah Hendra, Ellen Van Cann, Muhammad Ruslin, Jan de Visscher, Tymour Forouzanfar, Henrica de Vet

34. Towards tissue engineering application of cleft palate defects: A review. Diandra Sabrina N. Kalla, Faqi Nurdiansyah Hendra, Muhammad Ruslin, Melvin Maningky, Tymour Forouzanfar, Marco N. Helder

35. Long-term stability counterclockwise surgical advancement mandibular deficiency in patients with high mandibular plane angle. Part I – Dental and skeletal aspect. Muhammad Ruslin, Tymour Forouzanfar, R.B. Greebe, Dirk B. Tuinzing

36. Long-term stability counterclockwise surgical advancement mandibular deficiency in patients with high mandibular plane angle. Part II – Double and single surgery aspect. Muhammad Ruslin, Tymour Forouzanfar, R.B. Greebe, Dirk B. Tuinzing

37. The role of endodontics after tooth injuries to prevent root resorption: A review and case presentation. Syamsiah SyamSyam,, Andi Sumidarti,Sumidarti, A. A. S. S. Hajrah-Yusuf, Hajrah-Yusuf ,Aries Aries Chandra Chandra Trilaksana, Trilaksana ,M. M. Hendra Hendra Chanda, Muhammad Ruslin

38. Global perspective on facial deformity: Cultural and religious perspective. Hasanuddin, Muhammad Ruslin, Tymour Forouzanfar

141ͳͶͳ 142

Curriculum vitae

ͳͶ͵ Muhammad Ruslin, was born in Pangkajene, Indonesia on the 2nd of July 1973. He is currently an Associate Professor in Oral and Maxillofacial Surgery, at Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Hasanuddin University. He is also a Consultant of Oral and Maxillofacial Surgeon at Hasanuddin University Hospital and Dental Hospital Hasanuddin University. He graduated his Bachelor and Doctor of Dental Surgery from Faculty of Dentistry, Hasanuddin University, Makassar, Indonesia in 2000 and obtained a Master Degree in Oral and Maxillofacial Surgery from Faculty of Medical, University of Padjadjaran, Bandung, Indonesia in 2009. He had his residency training at Department of Oral and Maxillofacial Surgery Faculty of Dentistry, University of Padjadjaran, Bandung, Indonesia (2003-2009), he registered as Oral and Maxillofacial Surgeon by Indonesian College of Oral and Maxillofacial Surgeons in 2009, and he registered as Consultant of Oral and Maxillofacial Surgery by Indonesian College of Oral and Maxillofacial Surgeons in 2017. He did a visiting research fellow in Department of Oral and Maxillofacial Surgery, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama (Prof. Makoto Noguchi, DDS., PhD) (2014. Jan-Mar). He did a Clinical Fellow in Department of Plastic and Reconstruction Surgery, Chang Gung Memorial Hospital, Taouyuan, Taiwan (Prof. Lun Jou Lo.) (2015). Since 2012, he has been a PhD researcher at Department of Oral and Maxillofacial C Surgery/Oral Pathology, VU University Medical Center/Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands (Promotor Prof. Tymour Forouzanfar, MD., DDS., PhD., and copromotors Prof. D. Bram Tuinzing, DMD and Paolo Boffano, MD., PhD). His research and clinical interests include oromaxillofacial trauma, congenital anomalies, dentofacial deformities, temporomandibular joint disorders, stem cells/tissue engineering and surgical implants. He has established Celebes Cleft Center Foundation in 2011 as non-profit organization. He has been the councilor at International Association of Oral and Maxillofacial Surgeons, the vice chairman of the Indonesian College of Oral and Maxillofacial Surgeons and Director of Dental Hospital Hasanuddin University.

144 ͳͶͶ Maxillofacial Fractures Associated with Accidents: Epidemiology and Consequences - Fractures Associated Maxillofacial

Maxillofacial Fractures AssociatedMaxillofa cwithial F rAccidents:actures EpidemiologyAssociated and wit hConsequences Accidents: Epidemiology and Consequences Muhammad Ruslin

MUHAMMAD RUSLIN