Mandibular trauma: a two-centre study

Abstract

The aims of this study were to assess and compare epidemiological data on mandibular fractures from two European centres and to perform a review of the literature. Between 2001 and 2010, a total of 752 patients with a total of 1167 mandibular fractures were admitted to a hospital in Turin, and 245 patients with a total of 434 mandibular fractures were admitted to a hospital in Amsterdam. The mean age in Turin was 34.8 years and in Amsterdam was 32 years. The age group 20–29 years showed the highest incidence of mandibular fractures in both centres. The fractures were mainly the result of assaults, in agreement with several articles in the recent literature, followed by falls. The continuous long-term and multicentre collection of data on the epidemiology of maxillofacial trauma is important because it provides the information necessary for the development of preventative measures aimed at reducing the incidence of facial injuries.

The epidemiology of facial fractures varies widely in different countries. These differences can be explained by varying economic and social conditions, local patterns of behaviour, and laws.

The maxillofacial region is one of the most frequently injured areas of the body, and in particular the mandible is the second most frequently fractured adult facial bone because of its prominent and unprotected facial position. Furthermore, mandibular fractures can cause a variety of impairments, including temporomandibular joint syndrome, poor mastication, malocclusion, and chronic pain.

Knowledge of the epidemiology of mandibular fractures is critical for effective prevention and for the establishment of accurate trauma evaluation protocols. Therefore, the analysis of the aetiology, patient gender and age, types, and most common sites of fracture is crucial for a more detailed knowledge of these injuries. The continuous long-term collection of data on the epidemiology of maxillofacial fractures is important because it provides information necessary for the development and evaluation of preventative measures to reduce the incidence of facial injuries.

The aims of the present study were to report, assess, and compare epidemiological data on mandibular fractures from two European centres and to perform a review of the literature.

Materials and methods

This study was based on information obtained from two systematic computer-assisted databases that contain continuously recorded data on patients hospitalized with maxillofacial fractures treated surgically in the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin, Italy, and the Department of Oral and Maxillofacial Surgery, Vrije Universiteit Medical Centre (VUMC), Amsterdam, the Netherlands; the data used were recorded between 1 January 2001 and 31 December 2010. Both hospitals are university hospitals that accept all types of facial trauma, although other general hospitals treating facial fractures are present in both cities.

Only patients who were admitted with mandibular fractures were considered for this study. Patients affected by other associated fractures of the maxillofacial region and those with incomplete charts were excluded in order to reduce bias.

The following patient data were considered: sex, age, site and severity of facial fractures (Facial Injury Severity Scale, FISS), aetiology, associated dental injuries, and signs (malocclusion, inferior alveolar nerve paresthesia, mental lacerations). Mandibular fractures were categorized as symphyseal, body, angle, ramus, condylar, and coronoid fractures. Crown or root fracture, luxation, intrusion, and avulsion were considered in the category ‘associated dental injuries’, whereas dental concussions were not assessed.

The cause of injury was divided into six main categories: (1) motor vehicle accidents (MVA), which included accidents involving automobiles, motorcycles, and MVA – pedestrian accidents; (2) assault, which included interpersonal violence and attacks with weapons; (3) falls; (4) sports injuries; (5) bicycle accidents; and (6) other causes, which included pathological fractures, occupational accidents, domestic accidents, suicide attempts, accidents with animals, tooth extraction, and unknown aetiology.

This retrospective study was exempted from institutional review board approval. The guidelines of the Declaration of Helsinki were followed.

A statistical analysis was performed to identify associations among multiple variables. Statistical significance was determined using the χ 2 test, or Fisher’s exact test if the sample sizes were too small.

Results

During the time frame considered, 1818 patients with maxillofacial fractures were admitted to the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin (UNITO), and 523 patients were admitted to the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Centre (VUMC), Amsterdam.

Between 2001 and 2010, a total of 752 patients (563 males, 189 females) with a total of 1167 mandibular fractures not associated with further maxillofacial fractures were admitted to UNITO, and 245 patients (169 males, 76 females) with a total of 434 mandibular fractures were admitted to VUMC. The male to female ratio was 2.98:1 in the UNITO study population and 2.22:1 in the VUMC case series.

The mean age of patients in the UNITO study population was 34.8 years (range 5–99, median 30, standard deviation (SD) 18.5 years), in comparison to a mean age of 32 years in the VUMC patients (range 2–87, median 29, SD 15.2 years).

At UNITO, 402 patients presented a single mandibular fracture, giving a single-to-multiple fracture rate of 1.15:1, whereas at VUMC the single-to-multiple fracture rate was 0.39:1, with 69 patients out of 245 presenting a single fracture.

The monthly distribution of mandibular fractures in the two study populations is presented in Fig. 1 . The highest incidence of mandibular fractures in the VUMC series occurred between March and July, whereas the peak incidence of mandibular injuries in the UNITO series was observed in the months between April and August. The lowest incidence was observed in January and February in both study populations.

Fig. 1
Monthly distribution of mandibular fractures in the two study populations.

The age and gender distribution of the VUMC and UNITO study populations is summarized in Table 1 . The age group 20–29 years had the highest incidence of mandibular fractures in both centres (34% at VUMC, 30% at UNITO) ( Fig. 2 ).

Table 1
VUMC and UNITO study populations by gender and age.
Age, years Amsterdam (VUMC) Turin (UNITO)
Male Female Total Total % Male Female Total Total %
0–9 1 3 4 2% 3 4 7 1%
10–19 31 12 43 18% 108 34 142 19%
20–29 57 26 83 34% 182 34 216 30%
30–39 40 14 54 22% 123 37 160 21%
40–49 24 9 33 13% 59 19 78 10%
50–59 9 3 12 5% 39 15 54 7%
60–69 4 4 8 3% 20 13 33 4%
70–79 0 3 3 1% 20 17 37 5%
80+ 3 2 5 2% 9 16 25 3%
Total 169 76 245 100% 563 189 752 100%
VUMC, Vrije Universiteit Medical Centre, Amsterdam; UNITO, San Giovanni Battista Hospital, Turin.

Fig. 2
Age distribution of the two study populations.

Table 2 summarizes the causes of the fractures and their distribution according to gender in the two study populations. The fractures were mainly the result of assaults (27% at VUMC, 29% at UNITO), in agreement with several articles in the recent literature ( Table 3 ), followed by falls (20% and 24%, respectively). In the VUMC study population, bicycle accidents accounted for 20% of mandibular trauma, whereas in UNITO, the third most frequent cause was represented by MVAs (23%) ( Fig. 3 ). This distribution of mandibular fractures according to aetiology is consistent with those reported in previous articles ( Table 3 ).

Table 2
Distribution of aetiologies according to gender in the VUMC and UNITO study populations.
Cause Amsterdam (VUMC) Turin (UNITO)
Male Female Total P -value Total % Male Female Total P -value Total %
Assault 61 5 66 <0.0000005 a 27% 208 11 219 <0.0000005 a 29%
Fall 29 19 48 20% 94 89 183 <0.000005 b 24%
MVA 29 7 36 24% 122 55 177 23%
Bicycle 20 29 49 <0.000005 b 20% 30 17 47 6%
Sport 15 2 17 9% 60 9 69 10%
Other 15 14 29 11% 49 8 57 8%
Total 169 76 245 100% 563 189 752 100%
VUMC, Vrije Universiteit Medical Centre, Amsterdam; UNITO, San Giovanni Battista Hospital, Turin; MVA, motor vehicle accident.

a Aetiology presenting a statistically significant association with male gender.

b Aetiology presenting a statistically significant association with female gender.

Table 3
Aetiology of mandibular fractures: review of the literature.
Author Publication year Time period Country Cause
MVA Assault Fall Sport Bicycle Other
Olson et al. 1982 1972–1978 Iowa, USA 48% 34% 8% 2% NA 7%
Ellis et al. 1985 1974–1983 Scotland, UK 18% 51% 21% 4% NA 5%
Adi et al. 1990 1977–1985 Scotland, UK 17% 54% 18% 4% NA 7%
Fridrich et al. 1992 1979–1989 Iowa, USA 31% 47% 7% 5% NA 8%
Dongas and Hall 2002 1993–1999 Australia 13% 55% 5% 17% 5% 5%
King et al. 2004 7 years Illinois, USA 30% 49% 13% NA NA 5%
Qudah et al. 2005 1993–2002 Jordan 39% 18% 34% 7% NA 2%
Martini et al. 2006 2001 Brazil 31% 26% 12% NA 8% 11%
Sakr et al. 2006 1991–2000 Egypt 41% 16% 36% 5% NA 2%
Czerwinski et al. 2008 1998–2003 Canada 26% 41% 18% 10% NA 3%
Subhashraj et al. 2008 2000–2004 India 86% 6% NA NA NA 8%
Bormann et al. 2009 2000–2005 Germany 11% 28% 26% 10% 21% 4%
de Matos et al. 2010 2002–2005 Brazil 33% 22% 20% 5% 14% 6%
Chrcanovic et al. 2012 2000–2002 Brazil 27% 20% 19% 2% 16% 14%
Rashid et al. 2013 2005–2010 England, UK 4% 72% 18% 5% NA 2%
MVA, motor vehicle accident; NA, not available.

Fig. 3
Distribution of aetiologies in the two study populations.

A statistically significant association was found between male gender and the aetiology of ‘assault’ in both study populations ( Table 2 ). Furthermore, in the VUMC series, female gender was statistically associated with bicycle accidents, whereas in the UNITO series, female gender was statistically associated with falls ( Table 2 ).

An overview of the sites of mandibular fracture in the two study populations is presented in Table 4 and Fig. 4 . The most frequently involved fracture site at both VUMC and UNITO was the mandibular condyle, with 405 fracture lines (35%) in the UNITO population and 185 fractures (43%) in the VUMC series; this was followed by symphyseal/parasymphyseal fractures (307 (26%) and 110 (25%) fracture lines, respectively). The distribution of mandibular fractures is consistent with those reported in previous articles ( Table 5 ).

Table 4
Characteristics of mandibular fractures in the two study centres.
Fracture VUMC % UNITO %
Symphysis 110 25% 307 26%
Body 71 16% 136 12%
Angle 65 15% 301 25%
Ramus 2 0.5% 11 1%
Condyle 185 43% 405 35%
Coronoid 1 0.5% 7 1%
Total 434 100% 1167 100%
VUMC, Vrije Universiteit Medical Centre, Amsterdam; UNITO, San Giovanni Battista Hospital, Turin.

Fig. 4
Distribution of fractures by mandibular site in the two study populations.

Table 5
Epidemiology of mandibular fractures: review of the literature.
Author Publication year Time period Country Number of patients Number of fractures Mean age, years M to F ratio Ratio of single to multiple fractures Fracture site
Condyle Coronoid Ramus Angle Body Parasymphysis/symphysis
Olson et al. 1982 1972–1978 Iowa, USA 580 935 NA 3.5:1 NA 29% 1% 2% 24% 16% 22%
Ellis et al. 1985 1974–1983 Scotland, UK 2137 3462 NA 3.2:1 0.94:1 29% 2% 3% 23% 33% 8%
Adi et al. 1990 1977–1985 Scotland, UK 378 632 NA 2.98:1 0.89:1 26% 2% 4% 19% 26% 19%
Fridrich et al. 1992 1979–1989 Iowa, USA 1067 1515 NA 3.5:1 NA 26% 1% 2% 27% 11% 24%
Dongas and Hall 2002 1993–1999 Australia 251 385 35.9 4.5:1 1.1:1 24% 1.5% 2% 32% 18% 19%
King et al. 2004 7 years Illinois, USA 134 225 32 4.6:1 0.5:1 23% 6% 15% 21% 34%
Qudah et al. 2005 1993–2002 Jordan 703 892 38 2.5:1 NA 21% 2% 19% 22% 28% 8%
Martini et al. 2006 2001 Brazil 91 149 27.3 6.6:1 0.94:1 16% 2% 4% 12% 31% 27%
Sakr et al. 2006 1991–2000 Egypt 509 755 NA 3.6:1 1.5:1 19% 1% 1% 22% 21% 29%
Czerwinski et al. 2008 1998–2003 Canada 181 307 NA 3.5:1 0.7:1 25% 2% 4.5% 23% 14% 29%
Subhashraj et al. 2008 2000–2004 India 238 443 NA 5.1:1 0.83:1 22% 1% 3% 12% 6% 45%
Bormann et al. 2009 2000–2005 Germany 444 696 37 2.9:1 0.99:1 42% 0.3% 2% 20% 15% 21%
de Matos et al. 2010 2002–2005 Brazil 126 201 28 4:1 NA 28% 2% 4% 18% 25% 22%
Chrcanovic et al. 2012 2000–2002 Brazil 1023 1454 30.06 5.47:1 NA 30% 1% 2% 15% 24% 25%
Rashid et al. 2013 2005–2010 England, UK 1261 1994 NA 6.6:1 1.3:1 27% 1% 3% 30% 9% 31%
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Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Mandibular trauma: a two-centre study
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