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Epidemiological analysis of maxillofacial fractures in Brazil: A 5-year
prospective study
Bernardo Ferreira Brasileiro, DDS, MSc, PhD,
a
and Luis Augusto Passeri, DDS, MS, PhD,
b
Piracicaba, Brazil
CAMPINAS STATE UNIVERSITY
Objective. The aim of this study was to assess the characteristics of maxillofacial fractures in the Piracicaba region of Brazil
during a 5-year period and to delineate comparisons with worldwide facial fracture patterns.
Study design. A descriptive statistical analysis was developed based on data collected using a specifically designed clinical
survey of all patients who attended the Division of Oral and Maxillofacial Surgery at the Piracicaba Dental School from 1999 to
2004. Information regarding age, gender, etiology, and type of maxillofacial injury and its associated lesions were evaluated.
In addition, treatment modalities and complication rates during patient follow-up were assessed.
Results. A total of 1024 patients presenting 1399 maxillofacial fractures were analyzed. Patients’ ages ranged from 0 to 88 years
(mean age, 28 616.4 years). The ratio of men to women was 4:1. Most fractures were caused by traffic accidents (45%),
followed by assaults (22.6%), falls (17.9%), sports accidents (7.8%), and work accidents (4.5%). The prevalent anatomic regions
of facial fractures (in percentages) were the mandible (44.2%), the zygomatic complex (32.5%), and the nasal bones (16.2%).
Associated systemic lesions were found in 41.9% of patients, with prevalence for injuries to the upper (24.1%) and lower limbs
(15.4%). Patient management was considered to be conservative in 490 patients (47.9%), and surgical therapy was performed
in 493 patients (48.1%), of whom 399 (80.9%) were treated with open reduction and rigid internal fixation. Complications
occurred in 76 patients (7.4%), mainly due to infection and malocclusion.
Conclusion. The findings of this study indicated that epidemiological research of maxillofacial fractures allows the presentation
patterns of the most affected individuals and the nature of their lesions to be outlined according to the region evaluated.
Furthermore, treatment evaluation and complication rate analysis permits a more realistic interpretation of how patients should
be managed.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28-34)
Injuries of the maxillofacial complex represent one
of the most important health problems worldwide.
Particular interest is created by the high incidence and
diversity of facial lesions.
1-3
Moreover, maxillofacial
fractures are often associated with severe morbidity,
loss of function, disfigurement, and significant financial
cost.
3-5
The patterns of maxillofacial fracture presentation are
consistently influenced by geographic area, socioeco-
nomic status of the cohort, and the period of investiga-
tion.
6-12
According to reports of developing nations,
traffic accidents are the main cause of maxillofacial frac-
tures,
9,13-16
while data from developed countries pointed
to assaults being considered the most frequent etiology
of such fractures.
17-21
With regard to the anatomical
sites, mandibular and zygomatic complex fractures
account for the majority of all facial fractures and their
occurrence varies according to the mechanism of in-
jury and demographic factors, particularly, gender and
age.
22-24
The coordinated and sequential collection of
information concerning demographic patterns of maxil-
lofacial injuries may assist health care providers to record
detailed and regular data of facial trauma. Consequently,
an understanding of the cause, severity, and temporal
distribution of maxillofacial trauma permits clinical
and research priorities to be established for effective
treatment and prevention of those injuries.
25,26
Since the adaptation by Champy et al.
27
in 1978 of
Michelet et al’s technique,
28
surgeons have increasingly
used rigid internal devices to treat many maxillofacial
fractures because of the favorable results achieved.
29,30
The appropriate use of plates, miniplates, and screws in
such cases can be of great benefit as they can maintain
the position of the reduced bone segments and do so
without the need for intermaxillary fixation.
31,32
Several studies have been conducted to investigate
the epidemiological features of maxillofacial fractures
in different population groups, such as Austria,
11,25,26
England,
3
Germany,
18
Greenland,
22
Finland,
23
Iran,
9
Italy,
33
Japan,
7,20
Jordan,
4,15
New Zealand,
2,5
Netherlands,
34
Nigeria,
13,14,16
Norway,
8
Scotland,
6,24
South Africa,
12
Sweden,
17
United Arab Emirates,
10
and the United States.
1,19,21
However, few specific facial
a
PhD student in Oral and Maxillofacial Surgery, Piracicaba Dental
School, Campinas State University, Piracicaba, Brazil.
b
Associate Professor of Oral and Maxillofacial Surgery, Piracicaba
Dental School, Campinas State University, Piracicaba, Brazil.
Submitted for publication May 5, 2005; returned for revision Jun 21,
2005; accepted for publication Jul 9, 2005.
1079-2104/$ - see front matter
Ó2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2005.07.023
28
fracture epidemiology reports on any South American
country are found in the international literature,
35
and
no prospective study has ever been published about gen-
eral maxillofacial complex fracture analysis for this
region. The following study was developed to evaluate
the epidemiological characteristics of prevalence, treat-
ment modalities, and complication rates of maxillofacial
fractures in the Piracicaba region, Brazil, from 1999 to
2004. Comparison of results with similar studies in other
regions of the world is also discussed.
MATERIAL AND METHODS
This was an observational, prospective, longitudinal
study of patients presenting with maxillofacial frac-
tures, attending the Division of Oral and Maxillofacial
Surgery of Piracicaba Dental School, State University
of Campinas, over a 5-year period (from 1 April 1999
to 31 March 2004). Participation in the study required
the patient’s consent in accordance with the recommen-
dations of the National Health Committee eBrazilian
Health Department and was approved by the Research
Ethics Committee of this Institution. Each patient un-
derwent a clinical examination using a standardized
data collection form that was specifically developed to
investigate the epidemiological features of maxillofa-
cial trauma. Patients were evaluated, whether admitted
to the hospital or treated as outpatients at 7 Level I
Trauma Centers and the Oral and Maxillofacial Ambu-
latory of Piracicaba Dental School in the Piracicaba re-
gion, Sa
˜o Paulo State, Brazil.
Data regarding patient age, gender, socioeconomic
activity, etiology, nature and type of injury, and concur-
rent corporeal lesions were catalogued. Maxillofacial
fractures were distributed according to their etiological
factors in traffic accidents (automobile, motorcycle, bi-
cycle, and pedestrian motor vehicle accidents), assaults,
falls, sports, work-related accidents, and others. Protective
devices assessment was based on use of seatbelts, helmets,
andglassesaccordingtotheetiology. The fractures
were classified as mandibular fractures, zygomatic
complex fractures (including isolated orbital fractures),
maxillary fractures, isolated nasal bone fractures,
frontal fractures, and nasal-orbital-ethmoid complex
fractures.
36
Investigation also included treatments, follow-up
results, and trauma-associated complications. Patient
management was divided into conservative (without
reduction or fixation of skeletal fractures), surgical
(requiring at least 1 intervention for reduction and/or
fixation of the facial fractures), and untreated (compris-
ing patients who had refused treatment, had been
referred to other facilities, or died before treatment).
The surgical interventions used were closed reduction
(with arch bars, eye loops, and intermaxillary fixation)
or open reduction and fixation of bone segments with
wiring technique or internal rigid fixation with plates,
miniplates, and screws, as appropriate.
36
Complications
studied included infection, malocclusion, nonunion,
bone deformities, functional deficits (mandibular mo-
tion, ocular motility, visual acuity, and nasal obstruc-
tion), and hardware removal.
37
For the records, each
patient would not be dismissed from follow-up if any
sign of edema, hematoma, or abnormality was diag-
nosed. Besides, patients’ data could present more than
one type of complication.
Patients who had refused to participate in the research
or who had inadequately completed the form were ex-
cluded. Patients with isolated dental trauma (injuries
to teeth and alveoli), either associated with soft tissue
lesions or not, were not included. Data were presented
by descriptive statistical analysis.
RESULTS
During the 5 years of study, 1892 patients were
attended for maxillofacial injuries. A total of 1024 of
them were patients with facial fracture (818 men and
206 women, ratio 4:1) presenting 1399 fractures.
Patients’ age distribution is depicted in Fig. 1. The
mean age was 30.6 614.7 years, ranging from 2 to 88
years, while the average was 30.2 years for men and
32.2 years for women. According to the investigation
about social activity (Table I), 60.5% of patients had
Fig. 1. Age distribution of 1024 patients with maxillofacial
fractures.
Table I. Occupation distribution of 1024 patients with
maxillofacial fractures
No. patients (%)
Occupation Men Women Total
Economically active 553 (67.6) 67 (32.5) 620 (60.5)
Not economically active
Student 122 (14.9) 51 (24.8) 173 (16.9)
Unemployed 99 (12.1) 16 (7.8) 115 (11.2)
Dependent 44 (5.4) 72 (34.9) 116 (11.4)
Subtotal 265 (32.4) 139 (67.5) 404 (39.5)
OOOOE
Volume 102, Number 1 Brasileiro and Passeri 29
some professional occupation (67.6% for men and
32.5% for women), and 16.9% of the others were
students.
The causes of injuries are listed in Fig. 2. Traffic
accident was the most frequent etiological factor of
maxillofacial fractures irrespective of gender (46.2%
for men and 40.3% form women). Whereas the second
most frequent cause of injuries for men was assault
(23.9%); in women, traffic accidents were followed by
falls (34%). The other etiologies maintained a similar
hierarchy. Specific information concerning traffic acci-
dents is shown in Table II, which demonstrated that
bicycle accidents (33.6%) were the main cause of this
specific injury type. However, particularly for women,
the most observed type of traffic accident was auto-
mobile accident (44.6%). This injury type for men
(28.0% of traffic accidents were automobile accidents)
only ranked in third position of prevalence, after bicycle
(34.1%) and motorcycle accidents (29.1%).
In these patients, 1399 fractures were diagnosed, with
a prevalence of mandibular fractures (618, 44.2%) in
423 patients (ratio, 1.46 fractures per patient), and the
second most frequent fracture type was found in the
zygomatic complex (455, 32.5%), accounting for 398
patients. The fracture sites are presented in Table III.
Specific analysis of fracture etiology and sites revealed
different prevalence patterns. In traffic accidents the
most frequent types of fractures were mandibular
(49.7%) and zygomatic fractures (40.6%). The most
frequent types of fractures in falls were also mandibu-
lar and zygomatic (51.4% and 38.8%, respectively).
Assaults and work-related accidents were mainly re-
sponsible for zygomatic complex (35.1% and 50%)
and mandibular (25.5% and 36.9%) fractures, respec-
tively. There was an even higher discrepancy of results
in sports accidents, since nasal bone (38.8%) and zygo-
matic complex fractures (37.5%) were the commonest
lesions.
Data with regard to associated injuries in patients
with maxillofacial fractures demonstrated that 58.5%
of patients had some facial soft tissue lesion. Lacera-
tions (36.6%) and abrasions (35.4%) were commonly
diagnosed, while hematomas were seen less frequently
(22.8%). One or other type of concurrent corporeal
injury was also found in 41.9% of cases. Anatomical
distribution of concurrent lesions is detailed in Fig. 3.
There were 462 patients (45.1%) who were treated as
outpatients. Inpatients corresponded to 562 cases
(54.9%), with a mean period of hospitalization of 4.4
days for men and 4.6 days for women (ratio of men:-
women of 5.5:1). Patients considered as ‘‘untreated’’
accounted for 41 cases, including refusal of treatment
(73.2%), death (17.1%), and institution transfers
(9.7%). Conservative therapy was conducted in 490
Table II. Type of traffic accidents in patients with
maxillofacial fractures
Type of
traffic accident
Number of
patients
% of traffic
accidents
Bicycle accident 155 33.6
Automobile accident 143 31.0
Motorcycle accident 124 26.9
Pedestrian MVA 39 8.5
TOTAL 461 100.0
MVA, Motor vehicle accident.
Fig. 2. Causes of injuries of 1024 patients with maxillofacial
fractures.
Table III. Sites of maxillofacial fractures
Site No. patients (%)
Lower third
Mandible 423 (41.3)
Condyle 162 (15.8)
Symphysis 139 (13.8)
Body 133 (13.0)
Angle 113 (11.0)
Ramus 13 (1.3)
Coronoid 2 (0.2)
Middle third
Zygomatic complex 398 (38.9)
Zygomatic body 319 (31.2)
Zygomatic arch 38 (3.7)
Zygomatic body 1arch 41 (4.0)
Nasal bone 227 (22.2)
Maxilla 61 (6.0)
Le Fort I 23 (2.2)
Le Fort II 14 (1.4)
Le Fort III 6 (0.6)
Sagittal 10 (0.9)
Other 10 (0.9)
NOE 11 (1.1)
Upper Third
Frontal 25 (2.4)
Total 1024 (100.0)
NOE, Nasal-orbital-ethmoid complex.
OOOOE
30 Brasileiro and Passeri July 2006
cases (47.9%), and surgical treatment details of 493
patients (48.1%) may be seen in Table IV.
Patients were followed-up routinely, from 1 week
to 3.5 years, according to the severity of fracture, pa-
tient’s medical status, and post-trauma complication
management. Seventy-six patients experienced at least
1 complication (7.4%), out of a total number of 88
complications. Distribution of complications related to
fracture sites is listed in Table V. Infection was the
most prevalent complication overall (3.7% of patients),
and it was predominantly found in patients who had
mandibular fractures (81.6% of patients with infection
were in the mandibular fracture group). Characteristi-
cally, maxillary fractures developed more complications
related to malocclusion (62.5% of all maxillary compli-
cations) and the higher number of problems associated
with facial asymmetry was observed in zygomatic com-
plex fractures (58.3% of asymmetric results).
DISCUSSION
Epidemiologic surveys will vary with geographic
region, population density, socioeconomic status and
regional government, era in time, and type of facility
in which the study was conducted. Comparison of data
requires these factors to be considered.
1,6
Nonetheless,
there seem to be some congruent trends.
9,12
This study
was conducted between April 1999 and March 2004 in
the metropolitan region of Piracicaba city, in the south-
east of Brazil, covering a population of about 800 000
inhabitants. This region includes both rural and urban
areas, with more than half the population younger than
30 years, a ratio of men to women of 0.97:1, and regular
road traffic legislation (use of restraints, speed limits of
55 mph and restrictions about driving under the influ-
ence of alcohol) since 1995 (Source: IBGE [Brazilian
Institute of Geography and Statistics], Demographic
Census 2000).
Demographic data of maxillofacial fractures in this
region indicated that they were prevalent in men (4:1).
These results agreed with data of various regions of
the world.
3-5,8,9,15,17,19-21
It is interesting to note that
the cultural and socioeconomic characteristics of the
studied population may influence the rates of facial frac-
tures in women. In countries such as Greenland,
22
Finland,
23
and Austria,
25
where women participate
directly in social activities and consequently are more
susceptible to traffic accidents and urban violence, the
ratio of men:women incurring maxillofacial injuries can
be as low as 2.1:1.
25
More recently, Adebayo et al.,
16
in Nigeria, reported that women’s facial injury rates in-
creased from 8% to 18% between 1978 and 1991, show-
ing that certain economic conditions were necessary for
women to play a more active part in society. Conversely,
Ahmed et al.
10
published a much higher prevalence of
men than other studies (11:1). The authors mentioned
that the cultural features of the United Arab Emirates,
where men usually do outdoor work and few women
drive, may explain these results.
The most affected age group was from 21 to 30
years (32.7%), followed by patients ranging from 11
to 20 years (21.9%). Many surveys of maxillofacial
fractures reported same results concerning
age.
2,5,8,10,11,13,17,21,22,34
The possible explanation for
this was that individuals between the ages of 11 and 30
years frequently take part in dangerous exercises and
sports, drive motor vehicles carelessly, and are more
likely to be involved in violence.
13
Furthermore, in the
present research, data regarding occupation (Table I)
also confirm these trends about gender and age. Men
Table IV. Surgical treatment modalities according to
the site of maxillofacial fractures
Site
Closed reduction
(No. patients)
Open reduction
(No. patients)
RIF Wire 1IMF
Mandible 11 277 1
Zygomatic complex 36 129 —
Nasal bone 45 1 —
Maxillary 3 33 —
Frontal — 3 —
NOE 1 5 —
NOE, Nasal-orbital-ethmoid complex; RIF, rigid internal fixation;
IMF, intermaxillary fixation.
Fig. 3. Concomitant corporeal lesions in 1024 patients with
maxillofacial fractures.
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Volume 102, Number 1 Brasileiro and Passeri 31
aged 21 to 40 years in the active segment of the popula-
tion represent a group with intense social interaction
and higher rates of mobility, making them more suscep-
tible to transport accidents and interpersonal violence,
consequently leading to higher rates of maxillofacial
fractures.
6,13,16,23
Since the etiological factor has impor-
tant influence on maxillofacial fracture presentation,
specific studies are able to identify some trends regard-
ing age distribution. Iida et al.
18
studied 505 patients
sustaining maxillofacial fractures resulting from falls
in Germany, and noted a high proportion of older
cases. Age distribution analysis showed 2 peaks of inci-
dence in the fourth and eighth decades, supported by
the knowledge that these incidents are often related to
intrinsic factors such as neuromuscular and cognitive
impairment.
Traffic accidents are clearly important in the series of
maxillofacial fractures in developing
9,13,14,16
and devel-
oped
3,7,20,34
countries over the past 10 years, in line with
the findings of the present study. Even though traffic
rules and regulations have been enforced, seatbelt and
helmet use encouraged, and passive safety devices
have been introduced in motor vehicles, road traffic re-
mained the most important cause of maxillofacial frac-
tures.
14
Traffic accidents were the most prevalent cause
of facial fractures in this study, being the cause of injury
to 461 (45%) of the patients. Within the category of traf-
fic accidents, bicycle and motorcycle accidents and col-
lisions involving pedestrians deserved special attention
over the previous few years, playing a prominent role
in maxillofacial trauma etiology.
34
Bicycles are an im-
portant means of transportation in the Piracicaba region
and this has led to a significant number of cases (33.6%
of traffic accidents) in the results of this study.
Recently, assault has also been found to be the most
common etiology of facial trauma in many urban centers
in developed countries. H€
achl et al.
11
in Austria, Iida
et al.
18
in Germany, and Laski et al.
19
in the United
States demonstrated that developed countries have an
increased incidence of interpersonal violence as the
leading cause of facial injury. With the implementation
of programs to reduce road traffic accidents and the
advances in restraints, the ease of acquiring weapons,
and increasingly aggressive behavior in urban centers,
assaults have replaced road accidents as the leading
cause of maxillofacial trauma in these regions.
Maxillofacial fractures were prevalently represented
by mandibular fractures (41.3%) in this study. Previous
studies concur with these data.
2,5,9,10,13,14,16,19
Reports
with high values of traffic accidents tend to present jaw
fractures as the most frequent fracture site, with predom-
inance of condylar involvement,
10,18,23,34
as may be seen
in the present study data. In studies presenting significant
interpersonal violence scores, mandibular fractures pre-
dominantly involving the angle and body regions, and
zygomatic complex fractures may appear as the most
prevalent fracture location.
1,6,8,24
The incidence of injuries concomitant with maxillo-
facial fractures can vary widely, since there is ambiguity
about the definition of these lesions in the literature and
it depends on the frequency of certain injury mecha-
nisms in the studies.
34
Motor vehicle accidents are con-
sidered to be the most frequent cause of associated
injuries in maxillofacial trauma.
3,13,15,16
Populations
strongly influenced by work-related accidents
11
or daily
life and play accidents
25
presented lower rates of associ-
ated systemic lesions (20.7% and 19.6%, respectively).
Haug et al.
1
compared the etiological mechanism of in-
juries to their concomitant lesions in 402 patients with
facial fractures. They found that motor vehicle accidents
were responsible for 68.1% of these lesions, while
sports accidents accounted for 4.4%. The present study
findings are parallel to those of Haug et al.,
1
since traffic
accidents were related to 61.8% and sports accidents to
6.3% of associated corporeal lesions.
In the past 15 years, changes in maxillofacial trauma
management have been strongly influenced by innova-
tions in materials and technology,
16,38
since objectives
such as early recovery, segment stability, and patients’
comfort have been considered paramount in the
Table V. Trauma-associated complications of 1024 patients with maxillofacial fractures
Site of fracture, no. complications Total
(% of complications)Complications Mandible ZC Nasal Maxilla Frontal NOE
Infection 31 4 0 1 0 2 38 (43.2)
Malocclusion 13 1 0 5 0 0 19 (21.6)
Asymmetries 0 7 2 1 0 2 12 (13.6)
Hardware 6 2 0 0 0 0 8 (9.1)
Nonunion 6 0 0 0 0 0 6 (6.8)
Functional deficit 0 1 0 1 1 0 3 (3.4)
Malunion 2 0 0 0 0 0 2 (2.3)
TOTAL 58 15 2 8 1 4 88 (100.0)
ZC, Zygomatic complex; NOE, nasal-orbital-ethmoid complex.
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32 Brasileiro and Passeri July 2006
treatment of maxillofacial fractures.
35,36,39
Ansari
9
re-
ported in Iran, from 1987 to 2001, a marked predilection
for ‘‘simple techniques’’ and most patients were treated
by applying closed procedures. Although treatment of
facial fractures varies from surgeon to surgeon, it also
depends on the available instruments. Reports from the
United Arab Emirates
10
and Nigeria
16
confirmed this
practice and stated that open reduction and rigid internal
fixation of facial fractures has not become popular in
most developing countries mainly because of cost.
4
On
the other hand, Torgersen and Tornes
8
advocated that
miniplates’ osteosynthesis has become the standard pro-
cedure in their department, being used 4 times more
frequently than wire in open reduction and bone fixation.
One of the most noticeable features of this study was
that 99.8% (399 patients) of 400 cases treated under
open reduction and bone segment fixation were done
by rigid means of internal fixation. Routinely, patients
with fractures involving the dentate segments, who
were treated with RIF were placed in IMF intraopera-
tively. On completion of the procedure, IMF was re-
leased in all but one case. This was the management
of a 25-year-old male motorcycle accident victim, diag-
nosed with symphyseal mandibular fracture associated
with a left zygomatic complex fracture and a sagittal
maxillary fracture. These sites were treated with 2.0-
mm titanium miniplates. Additional IMF was instituted
for 30 days because of poor patient compliance with
treatment and his follow-up was uneventful. Only one
isolated patient was not treated with RIF, but underwent
wire osteosynthesis of symphyseal and right body man-
dibular fractures after interpersonal violence. Inade-
quate sterilization of the plate and screw package was
noted when the patient was already under general anes-
thesia. Thus, surgeons decided on a wiring technique
and IMF postoperatively for 6 weeks. No complications
were found during the patient’s follow-up. Therefore,
rigid means of internal fixation is the method of choice
for open reduction of maxillofacial fractures by this
Division.
According to the results of the present study, overall
maxillofacial fracture complications were found in
7.4% of patients, lower than data presented by other au-
thors, ranging from 11%
8
to 12.8%.
32
Local infections
were the major complication type, occurring in 3.7%
of cases. This corroborates the outcomes achieved by
Torgersen and Tornes,
8
who obtained an infection rate
of 4% in Norway, and Zachariades et al.,
32
who noted
that 3.3% of patients developed infection after rigid in-
ternal fixation in Greece.
The characteristics of the fracture locations and
degree of bone fragmentation also contribute to develop-
ment of postoperative complications. More specifically,
surgical repair of lesions involving the nasal-orbital-
ethmoid (NOE) complex are difficult, and cosmetic
and functional sequelae can occur more frequently after
injury. This study revealed that NOE fractures demon-
strated the highest rate of complications of all facial frac-
tures (36.4%), particularly due to asymmetries and
infection, which could be attributed to the complexity
of the anatomical site and bony comminution found
in these injuries.
9,17,32,37
Besides, comparison of com-
plication rates among different studies should consider
the casuistic, methodology, and subjectivity of data
interpretation.
8,32
Nutritional deficiencies and changes in general
health, substance abuse, and life-style, personal/oral
hygiene, and overall compliance (failed to take medica-
tions, to maintain feeding restriction, and to return for
follow-up) may markedly accentuate complication
rates.
40
Ahmed et al.
10
observed a low rate of complica-
tions (5.6%), particularly of postoperative infections,
emphasizing the use of prophylactic antibiotics and
patients’ compliance with postoperative instructions.
It seems plausible that these aspects have a strong asso-
ciation with the cases of infection, nonunion, and
poor union, which represented most of patients with
complications. Thus, identification of these features
can contribute to maximize patients’ management and
prevention of facial fracture complications. Finally,
the methodology of each study interferes considerably
with complication scores, since similar treatment proto-
cols and well-defined complication records should be
confronted when a pertinent comparison of population
management is desired.
The present study supports that regular epidemiologic
evaluations of maxillofacial fractures allow a detailed
analysis of these lesions, providing important sup-
port to install clinical and research priorities, since
risk factors and patterns of presentation can be identi-
fied. According to these data it seems reasonable to
assume that road traffic legislation enforcement and
continuous public education toward the use of restrain-
ing devices should be encouraged. Additionally, it should
be emphasized that these patients need postoperative
care and assistance and they should be closely followed,
particularly in cases of facial fractures submitted to
open reduction and rigid fixation in any region around
the world.
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Reprint requests:
Dr Luis Augusto Passeri, DDS, MS, PhD
Av. Limeira, 901-Centro Ciru
´rgico
Faculdade de Odontologia de PiracicabaeUnicamp
Piracicaba/CEP 13414-903 SP, Brazil
passeri@fop.unicamp.br
OOOOE
34 Brasileiro and Passeri July 2006
