Accepted Manuscript

Can a Facial Injury Severity Scale Be Used To Predict The Need For Surgical
Intervention And Time Of Hospitalization?

Tiago Gai Aita, MSc, Cecília Luiz Pereira Stabile, PhD, Cássia Cilene Dezan
Garbelini, PhD, Glaykon Alex Vitti Stabile, PhD

PII: S0278-2391(18)30118-6
DOI: 10.1016/j.joms.2018.02.002
Reference: YJOMS 58155

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 9 October 2017

Revised Date: 4 February 2018
Accepted Date: 6 February 2018

Please cite this article as: Aita TG, Pereira Stabile CL, Garbelini CCD, Vitti Stabile GA, Can a
Facial Injury Severity Scale Be Used To Predict The Need For Surgical Intervention And Time Of
Hospitalization?, Journal of Oral and Maxillofacial Surgery (2018), doi: 10.1016/j.joms.2018.02.002.

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 ACCEPTED MANUSCRIPT
Can a Facial Injury Severity Scale Be Used To Predict The Need For

Surgical Intervention And Time Of Hospitalization?

Tiago Gai Aita, MSc*, Cecília Luiz Pereira Stabile#, PhD, Cássia Cilene

Dezan Garbelini#, PhD, Glaykon Alex Vitti Stabile#, PhD.

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*Professor, Department of Dental Medicine, University Center of Maringá,

Brazil.

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#
Professor, Department of Dental Medicine, State University of Londrina, Brazil.

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Address correspondence and reprint requests to Dr Tiago Gai Aita: Av. Ayrton
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Senna da Silva, 200, Sl. 204 – Gleba Palhano, 86.050-460, Londrina, PR,

Brazil; e-mail: tgaita@hotmail.com; Cel. +55 (43) 9 9969-0456.

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Abstract

Purpose: To evaluate whether the Facial Injury Severity Scale (FISS),

proposed by Bagheri et al. in 2006, can predict intervention needs in an

operating room (OR), length of hospital stay, and the need for support by other

specialties.

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Patients and Methods: Data were collected from the medical records of

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trauma patients from a public tertiary hospital between January 2009 and

December 2015, related to age, gender, comorbidities, habits, history of

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maxillofacial trauma, etiology, and the presence and location of fractures and

lacerations, in addition to the type of treatment performed and period of

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hospitalization. A score was applied to each patient according to the FISS.
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Multinominal logistic regression models were adjusted and all analyzes were
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performed using the IBM statistical package "Statistical Package for Social

Science" (SPSS), version 17.0.

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Results: The final sample consisted of 469 medical records. Mean age was
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31.38 ± 14.13 years. Traffic accidents were the most frequent cause (41.2%)

followed by interpersonal violence (29.4%). The most commonly fractured bone

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was the mandible (32.9%), and the mandibular angle was the most affected

region (29.0%). Reports of alcohol intake resulted in a 100% increase in the

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need for treatment of fractures in an OR. Patients with FISS> 5 presented 18

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times the chance of needing intervention in an OR, and a greater possibility of

hospitalization longer than 3 days (< 0.01). The mean length of hospital stay

was 8.14 days ± 6.02, with a statistically significant longer hospitalization period

for smokers (p <0.0001). Patients with any type of comorbidity were more likely
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to require support from other specialties (p = 0.022), and those with FISS> 5

were 6.6 times more likely to need this support (p <0.0001).

Conclusion: Higher FISS values may predispose patients to a longer

hospitalization time, greater chances of being submitted to surgical procedures,

and the need for follow-up by other medical specialties.

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Introduction

In 2013, it is estimated that 973 million people worldwide suffered traumatic

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injuries that demanded specialized health care. Among them, 21.7 million

presented some type of fracture, 4.8 million died, and about 50% had skull and

facial injuries 1,2

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. Maxillofacial trauma can be considered one of the most
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devastating types of injury due to the emotional consequences and possibility of
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permanent deformity, as well as the social and economic impact it causes on a

health system 3,4.

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In the 1970s, there was a great concern in the medical sciences about
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reducing the mortality rate of trauma victims. Studies published between 1909

and 1978 showed these rates to be between 34 and 76% in patients with
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neurological traumatic injuries5. In order to facilitate the communication and

understanding of the severity of these lesions, the Glasgow Coma Scale was
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then created and is used worldwide until today. It is an example of the

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usefulness of a scale in trauma assessment and management6,7.

The use of a severity scale for maxillofacial trauma is potentially beneficial,

facilitating communication among healthcare professionals about the severity of

the injury through a standard classification. In addition, it could act as a

prognostic and predictive tool to enable clinicians to explain the extent of injury
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to the patient, family members and administrative staff 8. However, although

there have been several attempts to develop such a scale, there are still

situations in which the viability of their use is in doubt.

Between 2005 and 2012, at least 4 facial trauma severity scales were
8-13
proposed by different authors . Some studies have attempted to apply them

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in different regions of the world. Unfortunately, to date there are no studies

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available in the literature that have statistically validated the interrelations of the

data collected and the different indices of facial trauma, or presented new

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correlations between them 13-18.

Bagheri and colleagues, in 2006, proposed the Facial Injury Severity Scale

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(FISS), which has been used to grade the severity of facial injuries. It is
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represented as a numerical value according to the presentation of all facial
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injuries, with a higher score indicating greater severity . This scale has been

shown to result in significant correlations between treatment costs and FISS

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values of patients . However, the FISS score as an effective predictor of the
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length of hospitalization and the correlation between FISS and injuries to other

parts of the body have not yet been evaluated10.

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The objective of this study was to evaluate the correlation between FISS

scores and specialized treatment needs, length of hospital stay and need for
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operating room (OR) use, potentially contributing to better communication

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among healthcare professionals and between clinicians and hospital

management staff.

Patients and methods

A retrospective study was carried out from the data collected in hospital

charts of facial trauma patients treated in a public tertiary hospital between

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January 2009 and December 2015. The Universidade Estadual de Londrina

University Hospital is a public hospital with 265 inpatient beds and 35 ICU beds

that serves the metropolitan region of Londrina, which comprises approximately

1,067,214 people in Southern Brazil.

A specific form was developed for data collection, which was performed by a

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single evaluator (T.G.A.). Records with incomplete or illegible data were

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discarded. Data on age, gender, comorbidities, habits, history of maxillofacial

trauma, etiology, and the presence and location of fractures and lacerations, in

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addition to the type of treatment performed were collected. After analyzing the

charts, each patient received a score according to the FISS 10. FISS criteria and

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scoring used in the analysis are described in detail in Table 1. The need for
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evaluation and/or follow-up by other specialties, and time and modality of
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hospitalization were also verified.

The predicted variable evaluated was the value obtained on the FISS scale>
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5 (yes / no), because all patients with FISS > 5 needed surgical procedure in
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OR. As covariates, the following were considered; age (in years), gender

(male/female), comorbidities (yes/no), alcohol intake (yes/no), smoking

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(yes/no), and illicit drug use (yes/no).

The descriptive data analysis included absolute and relative frequency - for
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categorical data; mean and standard deviation - for quantitative data with
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normal distribution; and median and quartiles (Q1 and Q3) - for the quantitative

data that did not present normal distribution. The relation between predictors

and the outcome was analyzed using multinomial logistic regression models

and the FISS scale> 5. The models were adjusted for age (as a continuous

variable), gender, comorbidities, alcohol intake, smoking, and the use of illicit
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drugs. A regression model was runned to select the variables (unadjusted

model) and only those that remained significantly associated were included in

the final model (adjusted model). All analyzes were performed using the

“Statistical Package for Social Science” (SPSS), version 17.0 (IBM Corporation,

Armonk, NY, USA), at a significance level of 5%.

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This study was approved by the Research Ethics Committee involving

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Human Subjects of the State University of Londrina under protocol

56992116.6.0000.5231.

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Results

Four hundred and seventy-nine medical records were eligible for the study,

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however 10 (2.09%) were excluded for inconsistent data, thus, the final sample
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consisted of 469 (97.91%) medical records of facial trauma patients.
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The mean age of the patients was 31.38 ± 14.13 years, ranging from 1 to 80

years of age and the most affected age group was 20 to 39 years (77.3%). Men
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were responsible for 84.4% of all consultations, and the elderly were the least
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frequent age group, as shown in Figure 1.

The etiology of trauma is described in Table 2, with traffic accidents (41.2%),

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especially motorcycle accidents (19.2%), followed by interpersonal violence

(29.4%) as the most frequent etiological factors.

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A total of 748 facial fractures were identified in the 469 patients included in
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the study. As described in Table 3, the most commonly fractured bone was the

mandible (32.9%), followed by the zygoma (18.9%), and the orbital complex

(17.2%).
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There were 338 mandibular fractures (Figure 2), with the mandibular angle

(29.0%) being the most fractured site, followed by the parasymphysis (22.4%),

and the mandibular body (21.5%).

The FISS scores did not present normal distribution, with the median (Q1 -

Q3) and 90th percentile of 2.0 (1.0 - 4.0) and 5.0, respectively. Thus FISS> 5

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was established as the cut-off point for the regression models, which means

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that 10% of the highest values obtained on the scale varied between 6 and 16

(Figure 3).

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Regarding the treatment modality, the majority of patients, 303 (64.6%),

required surgical reduction and fixation of fractures. Other types of procedures

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were performed in 69 patients (14.7%) and no type of intervention in 97
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(20.7%). Table 4 shows that patients who reported alcohol intake and suffered
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facial trauma were twice as likely to require surgical intervention (p <0.0001)

and those with FISS> 5 were 18 times more likely to require intervention in the
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OR (P <0.0001).
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Among the patients who required some type of OR intervention, the mean

time of hospitalization was 8.14 days ± 6.02, and there was a statistically
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significant difference for smokers (p <0.0001) who presented twice the chance

of longer hospitalization than non-smokers. A significant difference was also

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found for patients with an FISS> 5 (p = 0.01), who were 18 times more likely to
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be hospitalized for more than 3 days compared to patients with an FISS <6

(Table 5).

When evaluating the need for attendance by other medical specialties, either

due to comorbidities or associated traumas, Figure 4 shows that the most

commonly associated clinic was orthopedics with 47 patients (10%), followed by

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Neurosurgery with 37 (7.9%). Table 6 shows that patients with some type of

comorbidity are 1.81 times more likely to require support from other specialties

(p = 0.022), and those with FISS> 5 are 6.6 times more likely (p <0.0001).

Discussion

The purpose of this study is unprecedented in the available literature

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regarding the attempt to clarify correlations between clinical findings and the

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use of a maxillofacial trauma scale, as well as validating assertions that can be

used clinically. Some articles present the evaluation of patients using trauma

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13-18 9,17
scales , while others compare the various types of existing scales .

Based on the sample studied in the present article, the FISS scale can be used

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to predict the length of hospital stay, the need for fracture reduction and fixation
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in the OR, and the need for multi-professional intervention.
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The results show that all patients with FISS> 5 required surgical intervention

in the OR. This finding is of great value to the communication between

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surgeons and hospital staff. It may also help in the decision of which trauma
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center the patient must be referred to, as well as the prediction of treatment

costs, since these patients are 18 times more likely to go through intervention
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under general anesthesia. Bagheri et al., when publishing this score in 2006,

already demonstrated a relation between higher treatment costs and a higher

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FISS10, but did not show the relation between FISS and the need for specialized
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surgical intervention, as there seems to be a cut-off score for this. Some studies

show a strong relation between alcohol intake and facial trauma, that is,
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patients with alcohol intake are more likely to suffer facial trauma . In

addition to this correlation, we found in the present study that alcohol intake
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results in twice the chance of needing some type of surgical intervention,

regardless of FISS number.

Bagheri et al.10 showed that the higher the FISS value, the greater the

chances of the patient being hospitalized; however, the authors emphasized

that this correlation is weak and added that one reason was because many

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patients need to be followed by other specialties. In the present study we found

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statistically significant differences for the FISS correlation with hospitalization

time, where patients with FISS values> 5 were 18 times more likely to be

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hospitalized for more than 3 days, regardless of the need for other specialties. It

should also be pointed out that smokers who suffered facial trauma had twice

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the chance of staying longer, a correlation that has not yet been reported in the
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literature and is probably due to their predisposition to comorbidities such as
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cardiovascular diseases, diabetes, and arterial hypertension, among others that

often require adjustment prior to surgery 22. It is important to emphasize that the
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length of hospital stay also depends on multiple factors that may not be
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associated with the trauma, such as OR schedules in each hospital. Since facial

trauma surgery is usually not an emergency, in hospitals with a limited number

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of operating rooms it may be postponed, a fact that occurs in the hospital

studied.
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Thorén et al. (2010)23, observed that 25.2% of patients with facial trauma
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have injuries in other parts of the body, requiring intervention by other

specialties. The author also stated that this percentage increases for patients

who have more than one facial fracture, reinforcing the idea that a higher FISS
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increases the chances of requiring involvement by other specialties . The

current study presents in absolute numbers, as in the work of Thorén23 and

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collaborators, that the clinics most often associated with facial trauma are

orthopedics and neurosurgery. Patients in this study who presented higher FISS

scores had a strong correlation with the need for intervention in other medical

specialties, probably due to the fact that the higher the number of fractures in

the face, the greater the magnitude of the trauma and the greater the chance of

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fractures or injury to other parts of the body. It was also clear that this need

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increases when the patient presents some type of comorbidity.

When evaluating the profile of patients with facial trauma, we noticed that

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young adult men still present the great majority of cases, as reported in the

literature13-16. However, there was a high proportional prevalence of facial

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traumas from interpersonal violence (29.4%), which was the second most
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common etiology. Of these traumas, the mandible represented the absolute
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majority of the fractures which differs from the literature that usually finds nasal

fractures as the most common 9,24,25, although in the evaluated hospital, isolated
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nose fractures are attended by otorhinolaryngology; therefore, they are not

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included in this sample. Among the mandibular fractures, the mandibular angle

was the most frequent, differing from the literature that generally presents the
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26,27
mandibular condyle as the most commonly fractured region . This probably

occurred due to the large number of traumas caused by interpersonal violence,

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with a different mechanism and location of the trauma, and consequently

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resulting in another pattern of fractures.

As mentioned earlier, other scoring systems for lesions according to the

characteristics of maxillofacial trauma are described in the literature.The

Abbreviated Injury Scale (AIS), based on the anatomy, was first proposed in

197128 and has been revised repeatedly. In 1974, Baker et al29 found that the
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severity and mortality of the injury changed regularly with the sum of the square

of the 3 greatest AIS grades in 3 different body areas, and the Injury Severity

Score (ISS) was proposed. The AIS-ISS indexes can not be used to

characterize the peculiarities of the severity of the maxillofacial lesion13. Other

scales that we can highlight are the New Injury Severity Score (NISS)

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developed by Osler et al30 (1997) however this was not as widely used or

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recognized as the ISS. The Maxillofacial Injury Severity Score (MFISS) by

Zhang et al. (2006)11, who, because they inherited the disadvantages of AIS,

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also had their use compromised13 and the Facial Fractures Severity Scale

(FFSS) proposed by Catapano et al.12 still little used in the literature13.

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The choice of FISS was based that is easily calculated and reliably predicts
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the severity of maxillofacial injuries as measured by the operating room charges

required to treat the facial injury10.

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Even though sample selection followed standards from previous studies,

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limiting factors need to be discussed. Firstly, minor injuries such as facial

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contusions and small soft tissue lacerations may not have been included in our

sample, since the emergency room (ER) medical team performs evaluation and
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sutures when there is no sign of bone fractures or significant maxillofacial

trauma. In our hospital, oral and maxillofacial surgery works “on call” and is
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summoned by the ER team when necessary, usually after patient initial

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evaluation and stabilization. Secondly, all patients were treated in the same

hospital according to the same protocols, so it is difficult to affirm with

vehemence if the correlations found here would be found in other trauma

centers. Likewise, decision making on surgical versus conservative treatment

for some cases depends highly on each team and its treatment philosophy. At
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the same time, the evidence presented here for the FISS regarding

hospitalization time, the need for other clinics, and the requirement for surgical

intervention show that this scale should continue to be applied, ideally in

multicentric studies, to increasingly develop a worldwide standard

communication scale.

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We conclude that the FISS scale can be used as a predictor of the

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predisposition for a longer hospital stay, the need for surgical procedures, and

the need for multi-professional treatment by other specialties.

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References

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2. Mackenzie EJ: Epidemiology of injuries: current trends and future challenges.

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3. Sastry SM, Sastry CM, Paul BK, et al: Leading causes of facial trauma in the

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TABLE 1 - Facial Injury Severity Scale (FISS)

Anatomic Region Fracture Type Score

Dento Alveolar 1
Mandible Body/Ramus/Symphysis* 2
Condyle/Coronoid* 1
Dento Alveolar 1

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Le Fort I** 2
Le Fort II** 4

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Mid-face Le Fort III** 6
Naso-Orbital-Ethmoid (NOE) 3

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Zygomatic Maxillary Complex (ZMC) 1
Nasal 1
Orbital roof/rim 1
Upper face
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Displaced frontal bone fractures 5
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Non-displaced frontal bone fractures 1
Facial Laceration Over 10 cm long*** 1
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Final Score
Note. The FISS is the summation of the above points in an individual patient.
* Score per fracture.
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** Unilateral Le Fort fractures are assigned half the numeric value.

*** Combined total length for all facial lacerations.
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Adapted from Bagheri et al. 2006 .
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TABLE 2– Absolute and relative frequency of the etiology of maxillofacial
trauma.

Etiology (n) (%)

Road traffic accidents 193 41,2

(Pedestrian accident) (19) (4,1)
(Car accident) (45) (9,6)
(Cycling accident) (39) (8,3)

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(Motorcycle accident) (90) (19,2)
Interpersonal violence 138 29,4
Simple fall 42 9,0

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Fall from height 28 6,0
Sports accident 25 5,3
Gunshot wounds 23 4,9

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Work accident 13 2,8
Animal accident 6 1,3
During tooth extraction 1 0,2

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Total 469 100
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TABLE 3 - Absolute and relative frequency of facial fractures.

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Fractures n %
Mandible 246 32,9
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Zygoma 141 18,9

Orbit 129 17,2
Alveolar 99 13,2
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Nasal bone 38 5,1

Le Fort I 25 3,3
Frontal bone 21 2,8
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Maxillary 20 2,7
Le Fort II 15 2,0
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Naso-orbital-ethmoidal 11 1,5
Le Fort III 3 0,4
Total 748 100
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TABLE 4 – Estimates of the unadjusted and adjusted multinominal logistic
regression model of patients with facial trauma submitted to Operation Room
procedures (n = 469).

Unadjusted model Adjusted model

β EP P OR (IC 95%) β EP P OR (IC 95%)
Age -0,01 0,01 0,23 0,99(0,98 -1,01)
Gender
Female -0,22 0,28 0,42 0,80 (0,47 – 1,38)

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Male
Comorbidities
Yes -0,02 0,28 0,95 0,98 (0,57 – 1,69)
No

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Alcohol intake
Yes 0,52 0,24 0,03 1,69 (1,05 – 2,71) 0,70 0,20 0,00 2,01 (1,36 – 2,99)
No

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Smoking
Yes 0,40 0,28 0,15 1,49 (0,86 – 2,55)
No
Ilicit drug use

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Yes -0,05 0,36 0,90 0,96 (0,47 – 1,95)
No
FISS
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>5 2,84 1,02 0,01 17,15 (2,30 – 2,93 1,02 0,00 18,69 (2,52 – 138,71)
127,69)
<6
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TABLE 5 – Estimates of the unadjusted and adjusted multinominal logistic

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regression model of patients with facial trauma hospitalized for more than 3
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days (n = 469).

Unadjusted model Adjusted model (P = 0,00)

β EP P OR (IC 95%) β EP P OR (IC 95%)
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Age 0,002 0,27 0,83 1,00 (0,99 – 1,02)

Gender 1,08 (0,63 – 1,87)
Female 0,08 0,01 0,77
Male
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Comorbidities
Yes -0,13 0,28 0,63 0,88 (0,51 – 1,50)
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No
Alcohol intake
Yes 0,44 0,28 0,06 1,55 (0,98 – 2,48)
No
Smoking
Yes 0,53 0,24 0,05 1,70 (1,00 – 2,90) 0,80 0,21 0,00 2,22 (1,46 – 3,37)
No
Ilicit drug use
Yes 0,24 0,37 0,52 1,27 (0,61 – 2,63)
No
FISS
>5 2,97 1,03 0,00 19,49 (2,61 – 145,41) 2,90 1,02 0,01 18,06 (2,43 – 134,07)
<6
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TABLE 6 – Estimates of the unadjusted and adjusted multinominal logistic

regression model of patients with facial trauma who needed attention from other
specialties (n = 469).

Unadjusted model Adjusted model

β EP P OR (IC 95%) β EP P OR (IC 95%)
Age 0,00 0,01 0,97 1,00 0(0,98 – 1,02
Gender

PT
Female 0,34 0,30 0,25 1,40 (0,78 – 2,51)
Male
Comorbidities

RI
Yes 0,56 0,28 0,05 1,76 (1,01 – 3,05) 0,59 0,26 0,022 1,81 (1,09 – 2,70)
No
Alcohol intake

SC
Yes 0,11 0,26 0,67 1,12 (0,67 – 1,87)
No
Smoking
Yes -0,11 0,29 0,70 0,90 (0,51 – 1,58)

U
No
Ilicit drug use
AN
Yes 0,05 0,37 0,89 1,05 (0,51 – 2,16)
No
FISS
>5 1,94 0,39 0,00 6,99 (3,23 – 15,12) 1,89 0,39 0,00 6,60 (3,08 – 14,14)
M

<6
D
TE
C EP
AC
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PT
RI
U SC
AN
M
D
TE
EP
C
AC
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PT
RI
U SC
AN
M
D
TE
EP
C
AC
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PT
RI
U SC
AN
M
D
TE
EP
C
AC
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PT
RI
U SC
AN
M
D
TE
EP
C
AC