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Research Article
Revised

Epidemiology of maxillofacial injuries during monsoon and non-monsoon season in India: a data-based retrospective study from a tertiary care dental teaching hospital

[version 2; peer review: 2 approved]
PUBLISHED 04 Mar 2024
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This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Background

Maxillofacial Injury (MFI) is a major public health concern that is multifactorial in etiology-road traffic accidents (RTAs), falls and violence. RTAs are the major cause of maxillofacial injuries (MFIs) in countries like India. Recent studies have shown that maxillofacial fractures (MFF) constitute a significant proportion of facial injuries seen in hospitals (56.5%). The incidence of maxillofacial fractures can vary depending on several factors, including age, gender, and environmental factors. Of particular concern is the impact of seasonal variations, such as the monsoon season, which lead to high incidence of maxillofacial fractures due to hazardous conditions.

Methods

A retrospective review of medical records was done in a tertiary-care dental teaching hospital was done.

Results

Data of 200 subjects including 154 males (77%) and 46 females (23%) with a mean age of 35.38 ± 16.541 years; age range: 1 – 80 years was analyzed. A total of 200 MFI’s were recorded between 2021 and 2022. Soft tissue injuries were reported in 37.5% of the cases in non-monsoon season and 42.3% of the cases during the monsoon season. Dentoalveolar fractures were reported in 6.2% of the cases during the non-monsoon seasons and 7.7% during the monsoon season. In this study, mandible was the most fractured bone (n=104,52%) followed by zygomatic complex (n=50, 25%). The frequently observed pattern among mandibular fracture was condyle 8.3% during the non-monsoon season and 2.9% during the monsoon season).

Conclusions

The results of the study indicate that mandibular fractures are most commonly seen in maxillofacial fractures, followed by fractures of the zygomatic complex. The study also reveals a higher incidence of soft tissue injuries and dentoalveolar fractures during the monsoon season. Further research is warranted to explore the factors that contribute to the seasonal variation in maxillofacial fractures for effective interventions to reduce their occurrence.

Keywords

Maxillofacial injuries, Road Traffic Accidents

Revised Amendments from Version 1

Tables and figures have been edited and renumbered as per the reviewers suggestion – Figure 1 was removed. Additional table has been added for sex distribution and maxillofacial injuries. Statistical tests used have been edited. Interpretation of the results have been added to improve the clarity. Discussion was edited as per the reviewer suggestion.

See the authors' detailed response to the review by Rui Santos

Introduction

Maxillofacial injury (MFI) is a broad term used to describe any form of damage or trauma to the structures of the face, including the jaw, teeth, and facial bones and associated soft tissues.1 Maxillofacial fractures (MFF), on the other hand, specifically refer to fractures or breaks in one or more of the facial bones, such as the mandible or zygomatic complex. It is important to note that while MFFs are a type of MFI, not all MFIs involve fractures.

MFIs are a significant public health concern, with a wide spectrum of severity that can range from minor injuries to life-threatening conditions.2 The incidence of maxillofacial fractures can vary depending on several factors, including age, gender, and environmental factors.

Recent studies have demonstrated that maxillofacial fractures are among the most frequent types of facial injuries seen in hospitals 56.5%.3,4 These fractures can involve different components of the facial skeleton, including the mandible, maxilla, zygoma, and orbital bones.3,4

Additionally, it is important to consider how environmental factors may affect the number of maxillofacial fractures in hospital settings. The monsoon season, for example, may result in an increase in maxillofacial fractures owing to slippery roads and pavements, reduced visibility, and fallen trees and electrical wires.

Healthcare providers must be aware of these trends and take steps to predict and manage maxillofacial injuries. Therefore, this research paper aims to compare the incidence and pattern of maxillofacial trauma in a hospital-based setting with a focus on environmental factors.

Methods

Study design

The present study was conducted in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences Manipal, Udupi, Karnataka, India. This study was based on a systematic computer-assisted database search that allowed extraction of retrospective data of the patients who reported to our outpatient unit with injuries from RTA from December 2021 to December 2022.

Data collection was initiated only after requisite approvals were obtained from the Scientific Committee and the Institutional Ethics Committee of Hospital (IEC:57/2022).

The requirement for informed consent was waived in view of the retrospective nature of the study and there being no direct contact with the study subjects. This study did not involve any intervention or therapy, and the research involved no risks to the subjects. Subjects’ names and identity were not disclosed in any way during or after this database review study. Subjects were identified by subject ID numbers only, and hence, patient data confidentiality has been maintained.

Subject screening, inclusion and exclusion criteria

Patients of both sexes and all age groups with clinically and radiographically diagnosed maxillofacial fractures (with or without contiguous bodily fractures/injuries) were included in this study. Patients with incomplete records were excluded from the study. Patients with isolated skull fractures and only minor superficial soft tissue injuries were excluded from our study.

No formal sample size was calculated and all 200 patients who met the inclusion criteria during the study period were included.

Data collection

The hospital records were assessed and data on age, sex and season during which injury occurred was collected. Data was also recorded for anatomic location of facial fractures, associated soft tissue and dentoalveolar injury. In records fractures had been classified as fractures of the mandible, zygomatic-maxillary complex (ZMC), orbital floor, nose, Lefort 1, 2, 3 and naso-orbital-ethmoid (NOE) fracture. Mandibular fractures included fractures of the symphysis, Para symphysis, body, angle, ramus, coronoid, and condyle (Table 1).

Table 1. Distribution of soft tissue injuries and various types of facial bone fractures between Monsoon and Non-monsoon seasons.

SeasonP-value
Non-MonsoonMonsoon
N%N%
Soft tissue injuryAbsent6062.5%6057.7%0.488
Present3637.5%4442.3%
DentoalveolarAbsent9093.8%9692.3%0.69
Present66.2%87.7%
Lefort 1Absent9599.0%10096.2%0.371
Present11.0%43.8%
Lefort 2Absent96100.0%10399.0%>0.99
Present00.0%11.0%
Lefort 3Absent9295.8%9995.2%>0.99
Present44.2%54.8%
Frontal boneAbsent8790.6%10197.1%0.053; Sig
Present99.4%32.9%
Palatal boneAbsent9396.9%10399.0%0.352
Present33.1%11.0%
Temporal boneAbsent9295.8%10399.0%0.147
Present44.2%11.0%
Zygomatic archAbsent7275.0%9894.2%<0.001; Sig
Present2425.0%65.8%
Naso orbito ethmoid boneAbsent9599.0%10298.1%>0.99
Present11.0%21.9%
Fronto-zygomatic suture areaAbsent9396.9%104100.0%0.109
Present33.1%00.0%
Pyriform rimAbsent9497.9%10298.1%>0.99
Present22.1%21.9%
Zygomaticomaxillary complex (ZMC)Absent6163.5%8783.7%0.001; Sig
Present3536.5%1716.3%
Orbital rimAbsent8992.7%104100.0%0.005; Sig
Present77.3%00.0%
Orbital floorAbsent7376.0%9288.5%0.021; Sig
Present2324.0%1211.5%
Orbital wallAbsent9497.9%10399.0%0.609
Present22.1%11.0%
Sphenoid boneAbsent96100.0%10399.0%>0.99
Present00.0%11.0%
Tympanic plateAbsent9599.0%10399.0%>0.99
Present11.0%11.0%
Nasal boneAbsent8588.5%9894.2%0.149
Present1111.5%65.8%
Sinus wallAbsent9396.9%104100.0%0.109
Present33.1%00.0%
Pterygoid plateAbsent9599.0%104100.0%0.48
Present11.0%00.0%
SymphysisAbsent96100.0%10197.1%0.247
Present00.0%32.9%
ParasymphysisAbsent9497.9%10096.2%0.684
Present22.1%43.8%
AngleAbsent9497.9%10197.1%>0.99
Present22.1%32.9%
BodyAbsent9194.8%9995.2%>0.99
Present55.2%54.8%
RamusAbsent9599.0%10399.0%>0.99
Present11.0%11.0%
CondyleAbsent8891.7%10197.1%0.091
Present88.3%32.9%
CoronoidAbsent9497.9%104100.0%0.139
Present22.1%00.0%

Statistical analysis

Statistical analysis was performed using SPSS-20.0 for the Windows Statistical Package (IBM Corporation, Armonk, NY, USA) and a p value of ≤0.05 was considered statistically significant.

Descriptive data were presented as mean ± SD or number (%), unless specified. Data for incidence of soft tissue injuries, dentoalveolar Injuries and various facial fractures were compared between the two seasons i.e., monsoon and non-monsoon using Chi-square or Fishers exact test.

Results

In one year, period between December 2021 to December 2022, data of a total of 200 subjects were recorded and analyzed. Out of these, 154 (77%) were males while only 47 (23%) were females. Male to female ratio was 3.28:1 (rounded to two decimal places). The mean age of study population was 35.38 ± 16.541 years (age range: 1-80 years). There was no significant difference in the distribution of soft tissue injuries and dentolalveolar fractures between non-monsoon and monsoon seasons (P=0.488 and 0.69) respectively. Fractures in Frontal bone (P=0.053), Zygomatic arch (P<0.001), Zygomaticomaxillary complex (ZMC) (P=0.001), and Orbital rim (P=0.005) and Orbital floor (P=0.021) were significantly higher in non-monsoon season than monsoon season. Among males, the fractures of zygomatic arch (P<0.001), zygomaticomaxillary complex (P<0.001) and Orbital floor (P=0.007) were significantly higher in non-monsoon than monsoon season. In females, orbital floor fractures were significantly higher in non-monsoon than monsoon season (P=0.054) (Table 2).

Table 2. Distribution of soft tissue injuries and various types of facial bone fractures between Monsoon and Non-monsoon seasons as per the sex.

FemaleP-valueMaleP-value
Non-MonsoonMonsoonNon-MonsoonMonsoon
N%N%N%N%
Soft tissue injuryAbsent1352.0%1047.6%0.7674766.2%5060.2%0.545
Present1248.0%1152.4%2433.8%3339.8%
DentoalveolarAbsent2288.0%2095.2%0.6146895.8%7691.6%0.343
Present312.0%14.8%34.2%78.4%
Lefort 1Absent25100.0%21100.0%-7098.6%7995.2%0.375
Present00.0%00.0%11.4%44.8%
Lefort 2Absent25100.0%21100.0%-71100.0%8298.8%>0.99
Present00.0%00.0%00.0%11.2%
Lefort 3Absent25100.0%21100.0%-6794.4%7894.0%>0.99
Present00.0%00.0%45.6%56.0%
Frontal boneAbsent2496.0%21100.0%>0.996388.7%8096.4%0.066
Present14.0%00.0%811.3%33.6%
Palatal boneAbsent25100.0%21100.0%-6895.8%8298.8%0.335
Present00.0%00.0%34.2%11.2%
Temporal boneAbsent2496.0%21100.0%>0.996895.8%8298.8%0.335
Present14.0%00.0%34.2%11.2%
Zygomatic archAbsent2288.0%21100.0%0.2395070.4%7792.8%<0.001; Sig
Present312.0%00.0%2129.6%67.2%
Naso orbito ethmoid boneAbsent25100.0%2095.2%0.4577098.6%8298.8%>0.99
Present00.0%14.8%11.4%11.2%
Fronto-zygomatic suture areaAbsent25100.0%21100.0%-6895.8%83100.0%0.096
Present00.0%00.0%34.2%00.0%
Pyriform rimAbsent2496.0%2095.2%>0.997098.6%8298.8%>0.99
Present14.0%14.8%11.4%11.2%
Zygomaticomaxillary complex (ZMC)Absent2288.0%1781.0%0.6863954.9%7084.3%<0.001; Sig
Present312.0%419.0%3245.1%1315.7%
Orbital rimAbsent2080.0%21100.0%0.054; Sig6997.2%83100.0%0.211
Present520.0%00.0%22.8%00.0%
Orbital floorAbsent2392.0%1990.5%>0.995070.4%7388.0%0.007; Sig
Present28.0%29.5%2129.6%1012.0%
Orbital wallAbsent2496.0%21100.0%>0.997098.6%8298.8%>0.99
Present14.0%00.0%11.4%11.2%
Sphenoid boneAbsent25100.0%2095.2%0.45771100.0%83100.0%-
Present00.0%14.8%00.0%00.0%
Tympanic plateAbsent25100.0%2095.2%0.4577098.6%83100.0%0.461
Present00.0%14.8%11.4%00.0%
Nasal boneAbsent2392.0%21100.0%0.4936287.3%7792.8%0.256
Present28.0%00.0%912.7%67.2%
Sinus wallAbsent2496.0%21100.0%>0.996997.2%83100.0%0.211
Present14.0%00.0%22.8%00.0%
Pterygoid plateAbsent25100.0%21100.0%-7098.6%83100.0%0.461
Present00.0%00.0%11.4%00.0%
SymphysisAbsent25100.0%21100.0%-71100.0%8096.4%0.25
Present00.0%00.0%00.0%33.6%
ParasymphysisAbsent25100.0%21100.0%-6997.2%7995.2%0.687
Present00.0%00.0%22.8%44.8%
AngleAbsent25100.0%21100.0%-6997.2%8096.4%>0.99
Present00.0%00.0%22.8%33.6%
BodyAbsent2496.0%2095.2%>0.996794.4%7995.2%>0.99
Present14.0%14.8%45.6%44.8%
RamusAbsent25100.0%21100.0%-7098.6%8298.8%>0.99
Present00.0%00.0%11.4%11.2%
CondyleAbsent25100.0%21100.0%-6388.7%8096.4%0.066
Present00.0%00.0%811.3%33.6%
CoronoidAbsent25100.0%21100.0%-6997.2%83100.0%0.211
Present00.0%00.0%22.8%00.0%

Discussion

Maxillofacial trauma can be caused by various factors including falls, assaults, sporting injuries and road traffic accidents. Of these, road traffic accidents and monsoon weather conditions have been identified as significant contributors to the incidence of maxillofacial injuries. Given the increasing prevalence of road traffic accidents and unpredictable weather patterns, it is important to understand the epidemiology of maxillofacial injuries and identify any underlying patterns or trends that may exist to help reduce their incidence.

Some regions show a correlation between monsoon season and an increase in facial fractures, possibly due to broken and slippery roads/pavements,5,6 falling objects, electrical wires, poor visibility and increased traffic congestion. This can lead to an increase in road traffic accidents and facial injuries. However, there is evidence to suggest that monsoon periods may have fewer cases of facial fractures as people may prefer to stay indoors in anticipation of rain.7

Understanding these trends and patterns can help develop preventive measures to improve public safety, especially in areas where monsoons are severe.

The incidence of maxillofacial fractures is higher in developing countries than in developed ones due to several factors such as the lack of adequate safety measures, poor road infrastructure and social factors.5,8

The increase in both the frequency and severity of maxillofacial injuries can be linked to the high dependence on road transportation and the growth of socio-economic activities in developing countries. Contributing to these injuries are poor road safety awareness, unsuitable road conditions, underdeveloped motorways, speeding, outdated vehicles without safety features, and a lack of helmets and seat belts, as well as violations of traffic laws.5,9 All these factors come together to create a high number of road traffic accidents in developing countries.

Men show higher incidence for MFI’s due to their greater involvement in high-risk activities, outdoor activities, anatomical differences, and behavioral differences such as risk-taking in comparison to women as only few of them drive a vehicle. This has resulted in an increase in the male: female ratio this is found to be consistent with the findings reported in other research papers.4,5,8

On analyzing the data, we found that soft tissue injury and dentoalveolar injury were not significantly associated with monsoon season, while zygomatic arch, zygomaticomaxillary complex, frontal, orbital floor and orbital rim fractures were significantly more common during non-monsoon season.

Our study was conducted in an environment with better road infrastructure, mandatory wearing of helmet and seatbelt rules and easy access to immediate medical care, which may have contributed to a lower incidence of maxillofacial trauma. This contrasts with previous studies that have reported a higher incidence of maxillofacial trauma in low-income countries with poor infrastructure and limited access to healthcare services.

Future studies that are planned shall have a database which includes patients over a longer period of time so that the database is much wider.

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Shukla AD, G S, Chakravarthy K et al. Epidemiology of maxillofacial injuries during monsoon and non-monsoon season in India: a data-based retrospective study from a tertiary care dental teaching hospital [version 2; peer review: 2 approved]. F1000Research 2024, 12:1377 (https://doi.org/10.12688/f1000research.134532.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
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PUBLISHED 04 Mar 2024
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Reviewer Report 05 Apr 2024
Rui Santos, School of Technology and Management, Polytechnic Institute of Leiria, Leiria, Portugal;  Integrated Researcher at the Statistics and Applications Center of the University of Lisbon, Lisboa, Portugal 
Approved
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The authors considered the majority of my comments during ... Continue reading
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Santos R. Reviewer Report For: Epidemiology of maxillofacial injuries during monsoon and non-monsoon season in India: a data-based retrospective study from a tertiary care dental teaching hospital [version 2; peer review: 2 approved]. F1000Research 2024, 12:1377 (https://doi.org/10.5256/f1000research.163022.r252544)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 20 Feb 2024
Rui Santos, School of Technology and Management, Polytechnic Institute of Leiria, Leiria, Portugal;  Integrated Researcher at the Statistics and Applications Center of the University of Lisbon, Lisboa, Portugal 
Approved with Reservations
VIEWS 19
The authors present a retrospective study of the etiology and the type of maxillofacial injuries depending on factors such as sex, age and monsoon season in India.

In this study, 200 maxillofacial injuries are analyzed from the ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Santos R. Reviewer Report For: Epidemiology of maxillofacial injuries during monsoon and non-monsoon season in India: a data-based retrospective study from a tertiary care dental teaching hospital [version 2; peer review: 2 approved]. F1000Research 2024, 12:1377 (https://doi.org/10.5256/f1000research.147594.r243082)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 13 Apr 2024
    anand deep shukla, Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal , Manipal Academy of Higher Education, Manipal, 576104, India
    13 Apr 2024
    Author Response
    Thank you for reviewing the manuscript. 
    Below are the comments raised by the 2nd reviewer along with the replies

    Query: The authors state "Univariate analysis was done by Student’s ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 13 Apr 2024
    anand deep shukla, Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal , Manipal Academy of Higher Education, Manipal, 576104, India
    13 Apr 2024
    Author Response
    Thank you for reviewing the manuscript. 
    Below are the comments raised by the 2nd reviewer along with the replies

    Query: The authors state "Univariate analysis was done by Student’s ... Continue reading
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12
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Reviewer Report 31 Oct 2023
Amit Sethi, Department of Oral and Maxillofacial Surgery, Henry M. Goldman School of Dental Medicine, Boston University, Boston, Massachusetts, USA 
Approved
VIEWS 12
The authors have done well to highlight the influence weather and environmental conditions can play on the number and type of maxillofacial injuries seen.

The authors have brought up a very unique factor which could influence the ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Sethi A. Reviewer Report For: Epidemiology of maxillofacial injuries during monsoon and non-monsoon season in India: a data-based retrospective study from a tertiary care dental teaching hospital [version 2; peer review: 2 approved]. F1000Research 2024, 12:1377 (https://doi.org/10.5256/f1000research.147594.r217295)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 19 Oct 2023
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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