Abstract
The aim was to report the distribution, frequency and aetiology of jaw fractures in patients treated at the University Hospital, Malmö, 1993–2003 and to compare two previous studies from 1952–1962 and 1975–1985. In 1993–2003, 461 patients, 137 women (mean age 42 years; range 15–82) and 324 men (mean age 28 years; range 17–59) were diagnosed and treated. Women were significantly older than men ( P < 0.001). The most frequent cause of jaw fractures was falls in women (45%). In men, interpersonal violence (46%) was most common followed by road traffic accidents (RTAs) (24%) mostly involving bicycles (14%). The frequency of falls in women and men was significantly different ( P < 0.001) as was the difference between violence in men and women ( P < 0.001). The proportion of fractures caused by RTAs was significantly higher in 1952–1962 than in 1993–2003 ( P < 0.001). There was a significant increase in the proportion of fractures caused by violence between the two studies ( P = 0.007). In 1993–2003 the proportion of fractures in women due to falls was significantly higher than in 1952–1962 ( P = 0.006). Violence has replaced RTAs as the main cause for jaw fractures in men; for women falling is the commonest cause.
The aetiology of jaw fractures has been the subject of many studies . Reports have indicated that interpersonal violence and road traffic accidents (RTAs) are the most common reasons for fractures of the upper and lower jaws . Large differences in aetiology have been reported. In studies from countries such as Kuwait, Nigeria, United Arab Emirates and Iran the most common (55–75%) cause of jaw fractures is RTAs , while in Europe, Australia and North American countries most fractures are due to violence . The large difference in reported prevalence has been attributed to a variety of contributing factors such as cultural differences, sex, age, traffic density, traffic laws and socioeconomic status.
B lomquist and C assel analysed the aetiology and frequency of jaw fractures treated at the maxillofacial clinic at the General Hospital in Malmö, Sweden between 1952 and 1962 . The main cause of fractures was RTAs. More than 80% of the fractures were localized to the mandible. E riksson and W illmar published a study of jaw fractures treated at the same clinic from 1975 to 1985 and a comparison was made between the two studies. They found violence was the most common aetiological factor, which correlated with the increased number of acts of violence reported by the Police Authority at that time. The compulsory use of seatbelts, which began 1975 in Sweden, was thought to be the main factor contributing to the decrease in vehicle traffic related maxillofacial trauma. In this study the most common site was the mandible (about 75%), but there was an increase in the number of maxillary fractures probably due to the changes in aetiology.
Malmö is a city undergoing change. Heavy industries such as ship-building have been replaced with office work, university and high-technology work. There has also been major foreign immigration and Malmö has become a multi-cultural city. Since 1990, the number of immigrants living in Malmö has doubled and today approximately 37% of the citizens in Malmö have a foreign background representing 174 different countries. Whether this has influenced the aetiology, frequency or type of jaw fractures treated at the Department of Oral and Maxillofacial Surgery at the University Hospital in Malmö (UMAS) today have not been evaluated. The aim of the present study (study 3) is to report the distribution, frequency and aetiology of jaw fractures diagnosed and treated between 1993 and 2003 and to compare these results with findings from 1952–1962 (study 1) and 1975–1985 (study 2) at the same clinic .
Patients and methods
Patients diagnosed with fractures of the jaws at UMAS, during 1993–2003, were identified from a survey of patient records. The patients’ data were collected and recorded on a standardized form, made to fit the parameters used in previous studies at the same clinic . The form included information regarding age, sex, aetiology, location and type of fracture. The mechanism of injury was recorded as traffic, violence, fall, work, sport or other. The type of RTA was divided into bicycle, car, motorcycle and pedestrian. Information on home address at the time of injury was collected from the Swedish Population Register.
Radiographic examinations were used to classify the location of the fracture; these included a panoramic radiograph, a posterior–anterior projection, lateral cephalogram and when necessary an occlusal projection of mandibular fractures. For maxillary fractures, occipito-mental projections, frontal or lateral tomographies were used.
The fractures of the mandible were classified as condyle, angle, ramus, symphysis or coronoid process. The classification of maxillary fractures was Le Fort I, Le Fort II, Le Fort III, lateral or comminuted according to K elly and H arrigan . Fractures of the alveolar process, zygomatic arch, nasal bones and orbital floor were not included in this study.
Statistical methods
Continuous data is expressed as median and percentiles (10/90) since normality could not be assumed. The non-parametric Mann–Whitney U -test (when comparing a continuous variable between two groups), χ 2 (when comparing frequencies between more than two groups) and Fisher’s exact test (when comparing frequencies between two groups) were used. All P -values below 0.05 were considered as significant. Statistical methods were performed using SPSS for Windows version 14.0 (SPSS Inc., USA).
Results
461 patients were treated for jaw fractures in Malmö between 1993 and 2003 ( Table 1 ). 137 women with a mean age of 42 years (range 15–82 years) and 324 men with a mean age of 28 years (range 17–59 years) were included in the study. Women were significantly older than men ( P < 0.001). At the time of injury, 32 (7%) of the women and 93 (20%) of the men were living in a rural area while 105 (23%) of the women and 231 (50%) of the men were living in the city of Malmö. Women living in the city were significantly ( P = 0.005) older than those living in the countryside; median ages 49 and 34 years, respectively. The age in men did not differ markedly in these groups.
| Women | Men | |||||
|---|---|---|---|---|---|---|
| Rural area ( n = 32) | City ( n = 105) | Total ( n = 137) | Rural area ( n = 93) | City ( n = 231) | Total ( n = 324) | |
| Age * | 34 (15–61) | 49 (16–84) | 42 (15–82) | 28 (18–56) | 28 (16–62) | 28 (17–59) |
| Type of accident † | ||||||
| Traffic | 14 (44) | 33 (31) | 47 (34) | 28 (30) | 50 (22) | 78 (24) |
| Car | 5 (16) | 5 (5) | 10 (7) | 8 (9) | 11 (5) | 19 (6) |
| Bicycle | 6 (19) | 21 (20) | 27 (20) | 13 (14) | 32 (14) | 45 (14) |
| Motorcycle | 1 (3) | 1 (1) | 2 (2) | 5 (5) | 3 (1) | 8 (3) |
| Pedestrian | 2 (6) | 6 (6) | 8 (6) | 2 (2) | 4 (2) | 6 (2) |
| Violence | 5 (16) | 10 (10) | 15 (11) | 35 (38) | 113 (49) | 148 (46) |
| Fall | 9 (28) | 53 (51) | 62 (45) | 11 (12) | 32 (14) | 43 (13) |
| Work | 0 | 0 | 0 (0) | 5(5) | 7 (3) | 12 (4) |
| Sport | 4 (13) | 4 (4) | 8 (6) | 10 (11) | 20 (9) | 30 (9) |
| Other | 0 (0) | 5 (5) | 5 (4) | 4 (4) | 9 (4) | 13 (4) |
| Type of fracture ‡ | ||||||
| Maxillary | 8 (25) | 16 (15) | 24 (18) | 17 (18) | 49 (21) | 66 (20) |
| Le Fort I | 2 (6) | 5 (5) | 7 (7/137) | 3 (3) | 6 (3) | 9 (3) |
| Le Fort II | 0 | 2 (2) | 2 (1) | 1 (1) | 7 (3) | 8 (2) |
| Le Fort III | 1 (3) | 0 | 1 (0) | 2 (2) | 2 (1) | 4 (1) |
| Lateral | 4 (13) | 7 (7) | 11 (8) | 5 (5) | 26 (11) | 31 (10) |
| Comminuted | 1 (3) | 2 (2) | 3 (2) | 6 (6) | 8 (3) | 14 (4) |
| Mandible | 26(81) | 93 (88) | 119 (87) | 83 (89) | 197 (85) | 280 (86) |
| Condyle | 15 (58) | 70 (75) | 85 (71) | 49 (59) | 109 (55) | 58 (56) |
| Corpus | 12 (46) | 27 (29) | 39 (33) | 41 (49) | 82 (42) | 123 (44) |
| Angle | 3 (12) | 10 (11) | 13 (11) | 16 (19) | 44 (22) | 60 (21) |
| Symphysis | 2 (8) | 3 (3) | 5 (4) | 7 (8) | 13 (7) | 20 (7) |
| Coronoid process | 0 | 1 (1) | 1 (1) | 0 | 4 (2) | 4 (1) |
| Ramus | 2 (8) | 1 (1) | 3 (3) | 4 (5) | 19 (10) | 23 (8) |
Data on the aetiology of jaw fractures are presented in Table 1 . The most frequent cause of jaw fracture in women was falls (45%), and RTA (34%) mainly bicycle accidents (20%). In men, interpersonal violence was the most frequent cause (46%), followed by RTA (24%), with 14% bicycle accidents. The frequency of falls in women and men was significantly different ( P < 0.001) as was the difference between violence in men and women ( P < 0.001). The median age for women who had sustained a jaw fracture following a fall was 70.5 years and for all other accidents 34 years. The corresponding median ages for men were 44 years and 27 years, respectively. These differences were statistically significant for women ( P < 0.001) and men ( P < 0.001). In men with jaw fractures caused by violence the median age was 26 years and for all other causes it was 30 years. In women the corresponding median ages were 36 years and 47.5 years, respectively. The differences were not statistically significant for men ( P > 0.1) or women ( P > 0.1).
Among women, the median age was significantly lower ( P = 0.002) in those with fractures due to RTAs (36 years) compared with other causes (53 years). The corresponding median ages for men were 29.5 years and 27 years, respectively, and this difference did not show significance ( P > 0.3).
Sporting injuries in women occurred in a younger age group (median age 22.5 years) than those who were injured due to other causes (median age 45 years) ( P = 0.004). The corresponding median ages for men were 24.5 years and 29 years, respectively, and this difference also showed significance ( P = 0.022).
The only significant difference in the aetiology for jaw fractures based on the area of domicile was that falls were more common for women in the city than in the countryside ( P = 0.041). Violence tended to be more frequent as an aetiological factor for men in the city than in the countryside ( P = 0.065).
The different types of fractures are presented in detail in Table 1 . Mandibular fractures were most common in women (87%) and men (86%). Fracture of the condyle was diagnosed in 71% of the women and 56% of the men. This difference in gender was statistically significant ( P = 0.005). Maxillary fractures were diagnosed in 18% of the women and 20% of the men. Lateral fractures were most common in both genders. Fractures of both mandible and maxilla were diagnosed in 28 patients (6%), of which 6 were women. There were no statistically significant differences in type of fracture in relation to living area or causes of jaw fractures.
Comparison between studies 1, 2 and 3
At the Department of Oral and Maxillofacial surgery, UMAS, 300 patients were treated for jaw fractures during 1952–1962 (study 1), 539 patients during 1975–1985 (study 2) and 461 patients during 1993–2003 (study 3). The age distribution of the patients is shown in Fig. 1 . Jaw fractures were most frequent in the 20–29-year age group in all three studies. There was a tendency for more fractures in the 80–89-year age group in the present study. The proportion of women throughout the studies increased; the difference between study 1 and study 2 was significant ( P < 0.01).
Data on the aetiology of jaw fractures in all three studies are shown in Table 2 . The proportion of fractures caused by RTAs was significantly higher in study 1 than in study 3 ( P < 0.001). There was a tendency for fractures due to RTAs to increase in the present study compared with study 2 ( P = 0.077). There was a significant increase in the proportion of fractures caused by violence between studies 1 and 3 ( P = 0.007) while there was a decrease between studies 2 and 3 ( P = 0.07). Falls tended to be more frequent as the cause for fractures in study 3 compared with study 1 ( P = 0.1); there was no difference between studies 2 and 3 ( P > 0.2). In study 3, occupational injuries were less common than in study 1 ( P = 0.006) and study 2 ( P = 0.002). Sport as an aetiological factor significantly increased between studies 2 and 3 ( P = 0.001) while there was no difference between studies 1 and 3 ( P = 0.11).
| Causes | 1952–1962 n = 300 * , n (%) | 1975–1985 n = 539 * , n (%) | 1993–2003 n = 461 * , n (%) |
|---|---|---|---|
| Traffic | 123 (41.0) | 120 (22.3) | 125 (27.1) |
| Violence | 78 (26.0) | 237 (44.0) | 163 (35.4) |
| Fall | 53 (17.7) | 118 (21.9) | 105 (22.8) |
| Work | 21 (7.0) | 37 (6.8) | 12 (2.6) |
| Sport | 15 (5.0) | 18 (3.3) | 38 (8.2) |
| Other | 10 (3.3) | 9 (1.7) | 18 (3.9) |
The distribution of causes of fractures by gender in all three studies is shown in Table 3 . There was a significant decrease in the proportion of fractures in men caused by RTAs between studies 3 and 1 ( P = 0.002); there was a significant increase where violence was the cause ( P < 0.001). The number of fractures in men due to falls was significantly lower in study 3 than in study 2 ( P = 0.048) while there was only a tendency between studies 3 and 1 ( P = 0.07). Work-associated fractures in men decreased significantly between studies 3 and 1 ( P = 0.018). In women, there was a significant decrease in fractures caused by RTAs between studies 3 and 1 ( P < 0.001) and between studies 3 and 2 when the aetiology was violence ( P < 0.001). In study 3, the proportion of fractures in women due to falls was significantly higher than in study 1 ( P = 0.006).
| Causes | 1952–1962 | 1975–1985 | 1993–2003 | |||
|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Male | Female | |
| n = 245 * , n (%) | n = 55 * , n (%) | n = 396 * , n (%) | n = 143 * , n (%) | n = 324 * , n (%) | n = 137 * , n (%) | |
| Traffic | 89 (36.3) | 34 (61.8) | 82 (20.7) | 38 (26.6) | 78 (24.1) | 47 (34.3) |
| Violence | 72 (29.4) | 6 (10.9) | 193 (48.7) | 44 (30.8) | 148 (45.7) | 15 (10.9) |
| Fall | 40 (16.3) | 13 (23.6) | 64 (16.2) | 54 (37.8) | 43 (13.3) | 62 (45.3) |
| Work | 21 (8.6) | – | 18 (4.5) | – | 12 (3.7) | – |
| Sport | 14 (5.7) | 1 (1.8) | 32 (8.1) | 5 (3.5) | 30 (9.2) | 8 (5.8) |
| Other | 9 (3.7) | 1 (1.8) | 7 (1.8) | 2 (1.4) | 13 (4.0) | 5 (3.7) |
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