falls are one of the most important causes of maxillofacial injuries , especially in developed countries , and are usually discussed together with motor - vehicle accidents , sport , violence , and work [ 1 - 7 ] .
other articles examined falls according to patient age ; i.e. , falls in the paediatric population   or in old patients , according to height , or according to the cause of the falls , such as slipping and tripping , loss of consciousness , epilepsy [ 16 - 18 ] , and bicycle accidents [ 19 - 21 ] .
the aim of the present study is to assess falls according to their height and consequences in the maxillofacial region .
this study involved a systematic computer - assisted database that has continuously recorded patients hospitalised with maxillofacial fractures at the division of maxillofacial surgery , san giovanni battista hospital , turin , italy , since january 2001 , with a software update in 2009 .
only patients who presented with a  fall  in the database field for  cause of injury  over the period from 1 january 2001 to 31 december 2013 were considered for this study . the field  mechanism of injury 
classified falls in four groups : from slipping , tripping or stumbling ( stsf ) , from loss of consciousness ( locf ) , from stairs ( saf ) , and from heights ( hf ) .
the group stsf was characterised by an accidental fall that had occurred on a level surface and resulted from a loss of control while walking , running , or playing , and could have happened indoors or out .
the second group were locf that had occurred on a level surface and occurred either outdoors or indoor due to several causes , such as lipothymia , syncope , psychoactive drug abuse , alcohol / drugs addiction , and neurological disorders .
the third group included saf that resulted from a loss of equilibrium while going down stairs .
the fourth group included hf , and were sub - classified according to height into low ( < 3 m ) and high falls ( > 3 m ) .
the following data were considered for each patient : age , gender , site and severity of facial fracture facial injury severity scale ( fiss ) , facial lacerations according to the mcfontzl classification system   as modified by roccia et al .
, associated injuries , type of treatment , and hospital stay . statistical analysis was used to search for associations among multiple variables , including age , gender , fiss , and fracture location .
statistical significance was determined using the  or fisher s exact test if the sample sizes were too small . the significance level was set at p < 0.05 .
in total , 557 patients ( 338 males and 219 females [ ratio 1.5:1 ] , mean age 51.5 years [ range 4 - 99 years ] ) were admitted to our division for maxillofacial fractures following falls . as reported in figure 1 ,
falls were less frequent in people younger than 20 years , and had a higher incidence in the decade from 70 and 79 years , followed by the sixth and the third decades .
moreover , an inversion of the male - to - female ratio was observed in the first decade and above 80 years .
patients distribution according to age and gender . subdividing the patients into three groups , children ( < 16 years ) , adults , and the elderly ( > 60 years ) ( figure 2 )
, we observe an inversion in the male - to - female ratio in the > 60 years group , particularly for stsf fractures .
comparison between causes of fall and patients age groups : a = 0 - 16 ; b = 17 - 59 ; c = > 60 .
stsf = falls from slipping , tripping or stumbling ; locf = falls from loss of consciousness ; saf = falls from stairs ; hf = falls from heights . in terms of fall aetiology
, facial fractures followed in 315 ( 56.5% ) stsf , 157 ( 28.2% ) locf , 55 ( 9.9% ) hf , and 30 ( 5.4% ) saf patients .
the falls occurred indoors in 327 patients and outdoors in 230 . in the stsf group , there were 210 indoor falls , mainly at home , versus 105 outdoors falls , mainly walking .
the locf falls ( 85 indoor and 72 outdoor ) resulted from lipothymia ( 83 patients ) , neurological disorders ( 34 patients , including 19 cases of epilepsy ) , alcohol abuse ( 22 patients ) , psychoactive drug abuse ( 9 cases ) , syncope ( 7 patients ) , and vertiginous syndrome ( 2 cases ) .
the hf falls ( 53 outdoors , 2 indoors ) occurred from heights < 3 metres in 19 patients and > 3 metres in 36 patients .
the first subgroup included 6 falls from rung ladders , while the second subgroup included 11 falls from scaffolding , 8 from balconies , and 4 from suicidal attempts .
figure 3 shows that among the 769 fractures of the facial skeleton , in the stsf , hf , and saf groups the middle third of the face was the most involved region and the orbito - zygomatic - maxillary ( ozm ) complex was the most frequent fracture , together with the mandibular condyle ( table 1 ) . in comparison , in the locf
falls , the lower third of the face had the highest percentage of maxillofacial injuries ( 56% ) and the condyle was the most common site of fracture .
the percentage tended to decrease with increasing height , to 28% in the hf falls .
stsf = falls from slipping , tripping or stumbling ; locf = falls from loss of consciousness ; saf = falls from stairs ; hf = falls from heights .
the hf group had the highest fiss score of 4.54 ( 4.21 ) ( 6.05 [ 4.51 ] for falls > 3 m and 1.68 [ 1.2 ] for falls < 3 m ) , whereas the fiss was 1.97 ( 1.53 ) in locf , 1.7 ( 1.53 ) in saf , and 1.57 ( 0.91 ) in stsf .
half of these were localised to the lower third of the face , mainly in the chin region .
as shown in figure 4 , most facial lacerations were located between the upper eyelids , or on the forehead , nose , upper and lower lips , and chin .
if we consider the facial lacerations according to the type of fall , a greater rate of lacerations per patient was observed in hf falls ( figure 5 ) .
comparison of causes of falls and maxillofacial fractures 
 
 stsf = falls from slipping , tripping or stumbling ; locf = falls from loss of consciousness ; saf = falls from stairs ; hf = falls from heights . 
  in total ,
114 patients ( 20.5% ) presented with associated injuries , which were mainly orthopaedic ( especially involving the limbs ) , followed by neurosurgical and thoracic ( particularly the costal bones ) ( table 2 ) .
overall , 80% of the patients with hf facial fractures had associated injuries , versus 30% for saf , 14% for stsf , and 10% for locf . 

number of concomitant injuries depending on causes of falls 
 
 stsf = falls from slipping , tripping or stumbling ; locf = falls from loss of consciousness ; saf = falls from stairs ; hf = falls from heights . 
  of the 557 patients admitted ,
the maxillofacial fractures required open reduction in 389 cases ( 69.9% ) and closed reduction in 91 cases ( 16.3% ) , while 77 patients did not require surgical intervention , including 46 stsf , 27 locf , 3 sf , and 1 hf . of the 77 non - operated patients , 57 were older than 60 years ( 74% ) , 19 were adults , and just one was under 16 years .
the hospital stay averaged 10.5 ( 9.27 ) days in hf , 4.8 ( 4 ) in locf , 4 ( 3 ) in stsf and 4.63 ( 3.36 ) in saf .
overall , a significant association was observed between older age and female gender ( p < 0.005 ; odds ratio [ or ] 1.83 ; 95% confidence interval [ ci ] 1.29 - 2.59 ) . in the stsf group
, a significant association was observed between age and female ( p < 0.005 ; or 2.11 ; 95% ci 1.34 - 3.32 ) . in the locf group , no association was found between age and gender , whereas adequate statistical analysis could not be done for the hf and saf groups because of the small numbers of females .
regarding fracture site , significant associations were observed between stsf and fractures of the middle third ( p < 0.0000005 ; or 3.01 ; 95% ci 2.3 - 3.94 ) , between hf and fractures of the middle third ( p < 00005 ; or 2.31 ; 95% ci 1.54 - 3.47 ) , and between saf and fractures of the middle third ( p < 0005 ; or 3.66 ; 95% ci 1.90 - 7.23 ) .
they are the main cause of injury in our division , as reported in recent articles .
the world health organisation   defined falls as  inadvertently coming to rest on the ground , floor or other level , excluding intentional change in position to rest in furniture , wall or other objects  .
the main risk factors reflect the multitude of health determinants that directly or indirectly affect well - being .
these are categorised into biological ( e.g. age , gender , race , chronic illness ) , behavioural ( e.g. multiple medications use , excess alcohol intake ) , environmental ( e.g. slippery floors and stairs , loose rugs ) , and socioeconomic ( e.g. low income and education levels , inadequate housing ) factors . unlike many previous studies of falls incorporating specific height inclusion criteria
this kinetic energy , along with the landing position , location of contact , and impact surface determines the injury pattern and severity .
falls on level surfaces ( 85% of patients ) were the most frequent cause in our study population . in more than half of the cases
, the falls followed slipping , tripping , or stumbling . in this category of falls ,
a person falls down immediately forward , backward or laterally , when walking or running , and often tries to use the hands for protection .
the stsf group consisted of almost equal numbers of adults ( n = 152 ) and elderly ( n = 148 ) . in agreement with several articles [ 8,10,31 - 33 ] , we observed a majority of females in the group over 60 , which could be partially explained by the longer life expectancy of females versus males .
furthermore , geriatric and orthopaedic studies showed a relationship between falls and osteoporosis , so that older women are more likely to present with fractures associated with osteoporosis [ 34 - 36 ] .
finally , traumatic events in the elderly are often related to intrinsic factors , such as neuromuscular and cognitive impairment , disturbances of balance and gait , environmental hazards , drugs ( psychotropic , polypharmacy ) , cardiovascular risk factors , feet and footwear , medical problems , depression , and cerebrovascular lesions . in the stsf patients , fractures of the middle third ( especially ozm fractures ) were predominant , as in the other groups , with the exception of locf patients .
the injury severity was lower than in the other groups , probably because in this type of fall the patient instinctively tries to stop the fall , thereby minimising the impact with the ground .
this explains the threefold greater frequency of orthopaedic  protection  injuries ( especially to the upper limbs ) in comparison with the locf group .
in contrast , locf is not associated with a protection mechanism because the patient falls down as an 
the patient with epilepsy has an increased risk of accidental injuries due to loss of the muscle tone and self - protective reflexes that minimise trauma during a fall . in our study population , locf
it was caused by lipothymia , often following hypotension , or fever following influenza , with amnesia for the traumatic event . in agreement with haug et
al .   and hung et al . , the lower third was the most frequently involved facial region in this group of patients . as halazonetis   postulated , we believe that loss of consciousness prevents the muscles of the body from contracting at the moment of impact with the ground
. consequently , the teeth are not clenched at the moment of impact , leaving the condyle unprotected .
the fact that most lacerations were observed on the chin following locf ( figure 5 ) seems to confirm the greater frequency of direct injuries to the anterior region of the mandible , with the transmission of forces to the condyle , as found in a previous study of ours .
stsf = falls from slipping , tripping or stumbling ; locf = falls from loss of consciousness ; saf = falls from stairs ; hf = falls from heights .
finally , the severity of facial fractures in locf , with no possibility of performing protective actions to attenuate the impact of the face with the ground , was demonstrated by the high fiss score , similar to that for hf < 3 m , higher than for stsf and saf .
we expected that falls from heights , such as from ladders , would produce more severe maxillofacial fractures than falls on a level surface . on the contrary , the maxillofacial fractures in the 30 saf patients involved mainly the middle third and they had an fiss score slightly greater than that of stsf , as also reported by yamamoto et al . .
the same protection reflex as in stsf likely occurs in saf to attenuate the severity of injury .
a progressive decrease in maxillofacial fractures of the lower third was observed as the height of the fall increased , with 59% in locf , 40% in stsf , 34% in saf , and 28% in hf .
hf is an important cause of maxillofacial trauma , frequently associated with severe injuries to multiple organs . in agreement with salonen
almost all 55 patients with maxillofacial fractures following hf were males , between 17 and 59 years .
believe that  these findings are partly because men are socially active and therefore more frequently encounter accidents  .
this statement was confirmed in our study , in which almost half of the hf occurred in the workplace .
maxillofacial fractures of the middle third were the most numerous in this group of patients .
however , we identified a relatively high percentage of craniomaxillofacial fractures involving the upper third , with frequent involvement of both walls of the frontal sinus .
furthermore , the fractures of the frontal sinus occurred mainly in patients who had fallen from heights > 3 m ( 17 of 36 versus 2 of 19 patients ) . these findings support the hypothesis of atanasijevic et al .
, who said that  the frequency of head injuries is the highest in falls from heights below 7 m  .
accidental fallers from height are more likely to fall headfirst  , with a consequent lower percentage of maxillofacial fractures of the lower third .
the relatively high incidence of associated neurosurgical lesions in this group seems to confirm such hypotheses .
finally , the severity and complexity of maxillofacial fractures determined by hf was demonstrated by the high fiss score and high percentage of treated patients ( 54 of 55 ) , with a consequent longer hospital stay .
falls and associated injuries are a priority issue for the national health systems in europe and elsewhere , especially considering the rapidly increasing life expectancy .
this study found that maxillofacial injuries associated with falls are influenced not only by age , but also by the nature of the fall .
we observed that falls on a level floor ( especially from slipping , tripping or stumbling ) are the most important cause of facial fractures , with females being the most involved in the elderly population .
furthermore , in falls on a level floor , the injuries are more severe when patients fall without an efficacious protection reflex to attenuate the impact with the ground .
we found that in injuries from loss of consciousness , despite the general prevalence of maxillofacial fractures of the middle third in falls , fractures of the lower third were more frequent , and that their percentage decreases as the height of the fall increases
. finally , the most severe maxillofacial and associated injuries occurred following the falls from heights , especially > 3 m. in summary , we believe that the mode of falling must be considered as a separate aetiological factor in maxillofacial trauma , so as to prevent and manage maxillofacial injuries following falls and increase the accuracy of investigations .
 abstractobjectivesin several epidemiological studies of maxillofacial trauma , falls were one of the most frequent causes of facial injury . 
 the aim of this study is to analyse the patterns of fall - related maxillofacial injuries based on the height of the fall.material and methodsusing a systematic computer - assisted database of patients hospitalised with maxillofacial fractures , only those with fall - related injuries were considered . 
 the falls were divided into four groups : falls from slipping , tripping or stumbling ( stsf ) , loss of consciousness ( locf ) , stairs ( saf ) , and height ( hf ) . 
 data on the age , gender , fracture site , facial injury severity scale ( fiss ) , facial lacerations , associated lesions , type of treatment , and length of hospital stay were also analysed.resultsthis study included 557 patients ( 338 males , 219 females ; average age 51.5 years [ range 4 - 99 years ] ) . in the over 60 age group , females were more prevalent in stsf than males . according to aetiology , stsf was the most frequent cause of maxillofacial fractures ( 315 patients ; 56.5% ) followed by locf ( 157 ; 28.2% ) , hf ( 55 ; 9.9% ) , and saf ( 30 ; 5.4% ) . 
 the middle third of the face was affected most frequently . 
 after locf , however , the inferior third was prevalently involved . 
 the majority of associated fractures , as well as the most severe injuries and greatest rate of facial lacerations , occurred secondary to hf.conclusionsthis study showed that fracture severity and site are influenced not only by patient age , but also by the nature of the fall . 
INTRODUCTION
MATERIAL AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS