Trends in the incidence, prevalence and years lived with disability of facial fracture at global, regional and national levels from 1990 to 2017

Introduction

Injuries place huge burden on all populations worldwide, leading to high morbidity or mortality, regardless of age, gender, or geographical region (Salomon et al., 2015). Approximately 25% of all injuries reported in the National Trauma Data Bank involve the face (Choi, Lorenz & Spain, 2020). Facial fracture is a predominant cause of morbidity in the United States (VandeGriend, Hashemi & Shkoukani, 2015), because among the body parts, the face is the most exposed part, and it lacks protection, leading to the fragility of facial bones. Further, facial nerves and muscles responsible for central conduction, sensations, expressions, and eye movements are positioned near the facial bones (Plaisier et al., 2000). Therefore, fracture of face bones can result in death or inconvertible sequelae such as intracranial injury and severe psychosocial disorders (Choi, Lorenz & Spain, 2020; Clavijo-Alvarez et al., 2012; Krishnan & Rajkumar, 2018). Face fracture sites are multiple including frontal bone, nasal bone, zygomatic bone, maxilla and mandible, among which mandibular fracture was reported to account for the most common anatomic sites (Lee, 2012). Specifically, the distribution of anatomic locations in facial fractures showed a gradual alteration tendency from 2005 to 2010 according to a regional survey (Roden et al., 2012). Regarding to gender, major facial fractures are recorded in males, especially for those who aged between 16 and 30 years (Haug, Prather & Indresano, 1990). The most common causes of face trauma are assault, fall, and motor vehicle collision based on an epidemiology study of facial fractures in the United States (Erdmann et al., 2008). According to different era, geographic, socioeconomic, and cultural factors, the order of these three leading frequent causes may change (Avansini Marsicano et al., 2019; Haug, Prather & Indresano, 1990; Simsek et al., 2007). Based on numerous literatures about facial fractures, the distribution of the etiology and pattern of facial fractures were mostly investigated (Alam et al., 2019; Fasola, Obiechina & Arotiba, 2003; Montovani et al., 2006; Thoren et al., 2009). Though a recent study of facial fractures has analyzed the Global Burden of Disease(GBD) 2017 study (Lalloo et al., 2020), they focused on the causes of facial fractures globally and referred briefly to the incidence, prevalence, and years lived with disability (YLDs) of facial fractures. In the present study, we investigated the incidence, prevalence, and YLDs of facial fractures among 195 countries or territories and 21 regions by calculating the change in cases (CIC) and estimated annual percentage changes (EAPCs) from 1990 to 2017 to evaluate the changing trends of facial fractures and analyze the correlation between age-standardized rates (ASRs) or socio-demographic index (SDI) and EAPC. Furthermore, we discussed the changing trends in the age and gender distribution of facial fractures from 1990 to 2017.

The GBD study contains the data of 354 diseases and injuries in 195 countries or territories around the world including information about facial fractures, providing an opportunity for the exhaustive estimation of the distribution, burden, and trends of facial fractures in various countries and regions. GBD study produces the incidence, prevalence and years lived with disability to quantify the health loss for non-fatal disease such as facial fractures, thus contributing to the comparison of facial fractures with other health-damaging injuries or diseases. Moreover, GBD covers the distribution of facial fractures among gender, age, SDI, region and country across a range of years, showing a changing trend of facial fractures. Indeed, many injuries or diseases showed a specific pattern with age or gender and may correlate with the social development. Therefore, GBD study which includes global data and cross-country comparisons might prompt current understanding of complex and multifactorial diseases such as facial fractures. In this study, we analyzed the GBD 2017 data of facial fractures and provided empirical evidence for policy makers in various countries or territories to adequately utilize the limited medical resources and formulate more targeted policies according to corresponding social development level, age distribution and gender difference in order to protect people from suffering facial fractures.

Materials & Methods

Results

Analysis of facial fracture incidence worldwide

From 1990 to 2017, the global incident cases of facial fractures rose from 5,405,814 to 7,538,663, increasing by 39.45%. Conversely, the EAPC of age-standardized incidence rate (ASIR) was 0.00 (−0.20 to 0.10), showing a downtrend, and the ASIR of facial fractures decreased from 100.47 per 100,000 persons to 98.47 per 100,000 persons over 28 years (Table 1). In addition, the incidence of facial fractures was 5,009,249 (4,113,772–6,093,590) in males, which was twice more than those in females, thus supporting the trend of ASIR.

Table 1:

The incidence of facial fractures, and its temporal trends from 1990 to 2017.

Characteristics	1990		2017		1990-2017
	Incident cases No. ×103	ASIR per 100,000 No.	Incident cases No. ×103	ASIR per 100,000 No.	CIC No.(%)	EAPC No.
Global	5405.81	100.47	7538.66	98.47	39.45	0.00
Sex
Male	3627.63	132.86	5009.25	130.14	38.09	−0.03
Female	1778.19	67.15	2529.41	66.16	42.25	−0.14
Socio-demographic index
High SDI	1630.33	175.66	1709.50	157.54	4.86	−0.50
High-middle SDI	1428.97	127.38	1749.21	127.83	22.41	0.20
Middle SDI	909.18	57.87	1511.64	71.92	66.26	1.01
Low-middle SDI	749.74	72.96	1456.72	85.58	94.30	0.50
Low SDI	674.05	98.35	1089.16	86.27	61.59	−0.60
Region
Andean Latin America	28.20	73.69	38.20	62.54	35.47	−0.08
Australasia	51.20	264.17	77.13	290.95	50.62	0.42
Caribbean	18.52	52.95	33.50	72.16	80.84	1.64
Central Asia	122.39	173.15	154.20	167.19	25.99	−0.39
Central Europe	387.03	315.87	337.91	310.03	−12.69	−0.06
Central Latin America	103.47	67.07	164.81	65.28	59.28	1.10
Central Sub-Saharan Africa	46.46	87.26	99.55	83.74	114.29	−1.49
East Asia	684.58	52.12	1157.96	77.53	69.15	1.60
Eastern Europe	607.99	274.19	532.37	267.97	−12.44	0.05
Eastern Sub-Saharan Africa	317.55	169.01	368.28	97.68	15.98	−1.57
High-income Asia Pacific	247.26	150.69	259.95	157.77	5.13	0.11
High-income North America	515.19	189.25	481.47	131.42	−6.55	−1.87
North Africa and Middle East	368.77	105.86	783.03	126.96	112.33	1.00
Oceania	3.73	57.65	9.61	75.33	157.89	0.66
South Asia	762.17	71.09	1443.65	81.63	89.41	0.38
Southeast Asia	206.85	43.37	329.18	49.03	59.14	0.34
Southern Latin America	65.11	130.99	95.91	149.05	47.31	0.45
Southern Sub-Saharan Africa	52.07	99.70	67.96	87.02	30.53	−0.47
Tropical Latin America	90.47	62.10	172.31	77.30	90.45	1.24
Western Europe	581.33	159.71	616.04	155.02	5.97	−0.29
Western Sub-Saharan Africa	145.48	77.52	315.65	74.96	116.97	−0.16

DOI: 10.7717/peerj.10693/table-1

Notes:

ASIR, age-standardized incidence rate; SDI, socio-demographic index; YLDs, years lived with disability; EAPC, estimated annual percentage change.

In 2017, a high number of facial fractures incident cases was recorded in India (1,127,438.84), China (1,104,811.30), and USA (432,104.19), whereas a few incident cases were recorded in Northern Mariana Islands (36.68), Dominica (41.64), and American Samoa (43.22). Syria recorded the highest (588.34/100,000 people) ASIR in 2017, whereas Indonesia had the lowest ASIR (30.40/100,000 people) among the 195 countries or territories (Fig. 1A). Moreover, the ASIR of facial fractures was highest in Central Europe (310.03) among 21 regions but lowest in Southeast Asia (49.03, Table 1). Furthermore, the ASIR of facial fractures displayed a specific pattern with the various SDI values of 21 regions in the 2017 data. The regions in which the SDI was approximately 0.5 had low ASIR of facial fractures, while those with SDI near 0.8 presented a high ASIR (Fig. 2).

From 1990 to 2017, the incident cases of facial fractures increased in 159 countries or territories, whereas the EAPC was negative in 48 countries. As shown in Table 1, the greatest increase of percentage change in incident cases of facial fractures was observed in Oceania (157.89%), whereas the most prominent decrease of CIC was observed in Central Europe (–12.69%). High-income North America recorded the lowest EAPC of –1.87, whereas Caribbean recorded the highest EAPC of 1.64. In addition, ASIR of facial fractures showed an average annual percentage change of less than zero in regions with high and low SDI quintiles (Fig. 3A). The trends of facial fractures over 28 years are presented in Fig. 4A. An obvious decline of ASIR was observed between 1995 and 2000 in high SDI quintile, and became stable subsequently. Additionally, a significant correlation was observed between EAPC and ASIR (ρ= –0.3842, P < 0.0001, Fig. 5A), while no association was found between EAPC and SDI (ρ = 0.0036, P = 0.9603, Fig. 5B).

Age and gender distribution of incidence, prevalence, and YLDs of facial fractures

From 1990 to 2017, in all regions, the incident, prevalent cases, and YLDs in connection with facial fractures were mainly assembled between the age of 15 and 49 years, followed by the age group of 50–69 years. In addition, in both sexes, these indices showed upward trends over time in people aged over 50 years and downward trends in people under 14 years. Notably, a dynamic equilibrium was observed in people aged 15–49 years across 28 years (Fig. 8).

Both in 1990 and 2017, the incidence rate of facial fractures showed double peaks at the age of 20–35 years and over 80 years in males (Figs. 9A and 9B). The incidence rate in females showed a flat pattern in different age groups except for those over 80 years and presented a sharp increase of incidence rate (Figs. 9A and 9B). The prevalence and YLDs rate of facial fractures increased gradually with age and reached the peak at age over 80 years in both sexes (Figs. 9C–9F).

In both sexes, the age-standardized incidence rate, prevalence rate and years lived with facial fractures showed a relatively stable trend globally from 1990 to 2017 (Fig. 10A).Interestingly, the above parameters in males were always twice higher than those in females. In Syria, where the heaviest global burden of facial fractures was observed, these parameters showed an upsurge in 2011, and similarly the gender proportion between females and males remained approximately 1:2, though a sharp increase was observed since 2011 (Fig. 10B).

Discussion

Our analysis based on the GBD study displayed the latest worldwide patterns and the trends in the incidence, prevalence, and YLDs of facial fractures. From 1990 to 2006, the ASIR, ASPR, and age-standardized YLDs rate of facial fractures showed a slow downward trend globally. However, since 2007, among both females and males, the facial fracture burden increased slightly. The facial fracture burden was more skewed towards males than females worldwide. These findings will provide basis for policy makers to allocate medical resources reasonably and determine the underlying causes of facial fractures, thus decreasing the incidence rate of facial fractures. In addition, considering the various developing trends of facial fractures in different SDI quintiles, more targeted policy should be applied.

As shown in Fig. 2, the ASIR, ASPR, and age-standardized YLDs presented a similar and specific pattern according to the different SDIs. Regions with higher SDI showed higher ASRs than those with lower SDI. Motor vehicle collision, fall, and assault are the top three causes of facial fractures (Avansini Marsicano et al., 2019). Therefore, the regions with high SDI had high motor vehicle numbers and traffic flux, which increased the incidence risk of road accidents and facial fractures indirectly. However, the high and low SDI quintiles showed a negative EAPC, indicating that these regions showed a downward trend annually between 1990 and 2017. The use rates of seat belt in facial fractures increased by 3% (1990–1995), 8% (1996–2000), and 15% (2000–2004) (VandeGriend, Hashemi & Shkoukani, 2015). Cormier et al. also demonstrated the importance of using seat belts in the mitigation of facial injuries (Cormier & Duma, 2009). Hence, the increase in the use of seat belts, helmets, and advanced car models and the strict control of road traffic may contribute to the negative EAPC of facial fractures in regions with high SDI quintile (Czerwinski et al., 2008; Erdmann et al., 2008). The development and application of 3D printing technology has also been increasingly mature in the last three decades (Liu et al., 2018), thereby improving the cure rate of facial fractures in developed countries or territories. Regions with low SDI showed low age-standardized incidence rate, prevalence rate and years lived with disability, which may be attributed to the hysteretic medical level and insufficient diagnosis ability (Erdmann et al., 2008; VandeGriend, Hashemi & Shkoukani, 2015). Moreover, the probability of occurrence of motor vehicle collisions, as one of the main causes of facial fractures, is low in regions with low SDI (Alam et al., 2019). However, regions with middle and high-middle SDI showed high EAPCs, indicating a potential developing trend of facial fractures in the future. Considering the economic growth in these regions, the numbers of motor vehicles increased, whereas the corresponding road laws and regulations did not keep the path, thus increasing the incidence, prevalence, and YLDs of facial fractures. The economic growth may also prompt the advancement of medical equipment to raise the diagnosis numbers of facial fractures.

The EAPC of ASIR, ASPR, and age-standardized YLDs had no correlation with SDI, because the fracture mechanisms and risk factors of facial fractures are irrelevant with the SDI or regions. Conversely, EAPC showed negative correlations with the ASRs of incidence, prevalence, and YLDs. Facial fractures aggravated the health and financial burden globally. The total hospitalization charges for facial fracture in the United States were $1.06 billion in 2008 (Nalliah et al., 2013). Accordingly, the government may implement all kinds of effective measures such as punishing the drunk drivers strictly and propagating the use of seat belts and helmets to decrease the health and financial burden of facial fractures. Therefore, EAPC is shown to be inversely related to ASIR, ASPR, and age-standardized YLDs in 194 countries or territories.

As shown in Fig. 8, facial fractures were less frequent in children, and the ASPR of patients with facial fractures increased equally with age (Fig. 9), supporting the results of Imahara et al. (2008). Family care, reduced outdoor activities, and increased observations (Montovani et al., 2006) on children resulted in the low incidence, prevalence, and YLDs. In addition, the high bone elasticity and thick soft-tissue layer strengthen the resistance of children against facial fractures, especially maxillary and Le Fort fractures, because the frontal, ethmoid, sphenoid, and maxillary sinuses of children tend to be small and lack pneumatization (Chan et al., 2004; Thoren et al., 2009). Over 28 years, the proportion of facial fractures in various age groups was gradually altered, the groups aged under 15 years showed a decline of ASRs from 1990 to 2017, whereas those aged over 50 years showed an upward trend. This change can be linked to the demographic alteration worldwide. The population of the world is aging gradually because of the increase in life expectancy (Liu et al., 2019), which may lead to the ascending tendency of facial fractures incidence, prevalence, and YLDs among senior citizens, while the low fertility rates of many regions (Nogami et al., 2019) and the growing attention to children safety may lead to the downward trends of pediatric facial fractures globally. As shown in Fig. 9, both in males and females, the prevalence rate and YLDs rate increased with aging in 1990 and 2017. Falls are the most common cause of facial fracture among elderly patients (Atisha et al., 2016; Erdmann et al., 2008). The high risk of facial fractures among the elderly patients might have several causes, including the deficiency of the balance and strength while moving or resisting crashing and the tendency to suffer from various age-associated comorbidities, such as osteoarthritis and visual impairment (Atisha et al., 2016). The most commonly injured sites in elderly patients are the mandibular and nasal bones (Wade, Hoffman & Brennan, 2004), and associated injuries from facial fractures occur often and are severe in geriatric patients, leading to a high death rate (Toivari et al., 2016). The elderly individuals will account for 20% of the population in the United States of America in 2030, and a similar figure can be recorded in other developed countries (Vlavonou, Nguyen & Toure, 2018). Therefore, effective measures should be implemented to immediately prevent elderly people from suffering from facial fractures.

Interestingly, unlike females, the incidence rate of facial fractures in males also peaked at people aged between 25–29 years both in 1990 and 2017. Moreover, as shown in Fig. 10, the ASIR, ASPR, and age-standardized YLDs were always twice higher in males than those in females from 1990 to 2017. This finding may be related to the “high risk” recreational activities among young males, such as bicycling and sports (Plawecki et al., 2017) and that men are involved in driving (Montovani et al., 2006). In an Indian survey, the increased incidence of facial injuries and fractures among young men was explained by the reluctance to use helmets, exceeding speed limits, lack of tolerance, and increasing competition (Subhashraj, Nandakumar & Ravindran, 2007). Syria recorded the highest ASRs of facial fractures worldwide. Therefore, we analyzed the changing trend of ASIR, ASPR, and age-standardized YLDs in males and females since 1990 in Syria, and the data showed a sharp increase of ASIR, ASPR, and age-standardized YLDs in 2011. We considered an association with the explosion during the Syrian war in 2011 (Hayani, Dandashli & Weisshaar, 2015). Moreover, the ratio between males and females did not substantially change before and after 2011.

Conclusions

In conclusion, the incident cases, prevalent cases, and YLDs of facial fractures increased worldwide. By contrast, the ASRs showed downtrends globally. EAPC showed a correlation with the ASRs of facial fractures and was hardly associated with SDI. The ratio between males and females approached 2:1. Besides, the proportion of children and elderly suffering from facial fractures slightly changed with time. Facial fractures occurred more in young men aged between 25–29 years and in the elderly aged over 80 years in both sexes.

To our best knowledge, this study was the first to systematically investigate the changing trends of incidence, prevalence, and YLDs in facial fractures from 1990 to 2017 at the global, national, and regional levels. However, this study has some limitations. The accuracy of results depended on the quality and quantity of GBD data. For instance, the method utilized in the GBD study cannot provide access to cover all districts worldwide, and the opportunity to be diagnosed with facial fractures was not equal between developed and less developed countries because of differences in specialized medical care and imaging resources. Besides, in this text, we focused solely on the changing tendency of facial fractures in incidence, prevalence, and YLDs and did not analyze the trends of causes leading to facial fractures at the global, national, and regional levels from 1990 to 2017, which could be discussed in future research.

Totally, government in various countries or regions should formulate more targeted policies to reduce the incidence of facial fractures. For example, attention should be paid more on traffic control in regions with high SDI whilst in regions with low SDI, improvement of diagnosis ability of facial fractures should be more concerned. It is also essential to promote relevant protection awareness on entertainments with high risk in public, especially among young males. Moreover, the enormous health burden of facial fractures caused by warfare should not be neglected. With the increasing pattern of life expectancy globally, elderly people should be more focused on.

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