Maxillofacial fractures in a Norwegian district

Trauma; 0ral surgery

Maxillofacial fractures in a Norwegian district

Sissel T o r g e r s e n la, Knut T o m e s 1 1Department of Oral and Maxillofacial Surgery, Haukeland Hospital, Bergen, and Department of Orar Surgery and Oral Medicine, School of Dentistry, University of Bergen, 2Department of Dental Materials, School of Dentistry, University of Bergen, Bergen, Norway

S. Torgersen, K. Tomes." Maxillofacial fractures in a Norwegian district. Int. J. Oral Maxillofac. Surg. 1992; 21." 335-338. © Munksgaard 1992 Abstract. Records of 169 patients referred to Haukeland Hospital, Bergen, Norway, for treatment of maxillofacial fractures during the period 1989-91 were studied with respect to socio-etiologic aspects, frequency and localization of jaw fractures, treatment, and complications. The n u m b e r of maxillofacial fractures found in the present study was about twice as m a n y as found in a study from the same area during the period 1974-9. Recent trends in the etiology of maxillofacial traumas were confirmed, such as increased n u m b e r of fractures caused by interpersonal violence, and a reduction of cases related to traffic accidents. Alcohol abuse was a contributing factor in 28% of the patients. M a n d i b u l a r fractures were 4.8 times more frequent than maxillary fractures. Reduction and fixation with miniplate osteosynthesis was the preferred treatment in most patients.

The n u m b e r of fractures of the facial skeleton has increased over the past decades 1'6J9. It has been suggested that interpersonal violence has replaced road traffic accidents as the major cause of jaw fractures 6. It has also been found that young people are particularly prone to sustain maxillofacial fractures 1'6,12'2°'22,and that fractures affecting the jaws often seem to be combined with alcohol abuse 18,2°. These trends support the notion that maxillofacial fractures may be more related to socioeconomic factors than are fractures of other parts of the skeleton 18,2°. The treatment of maxillofacial fractures has largely been shifted from intermaxillary fixation and wire osteosynthesis to rigid internal fixation 3. Open reduction and fixation with miniplates has been established as a safe and reliable treatment, reducing the necessity of intermaxillary fixation 3. Wound infection and dehiscence are reported to vary from 4 to 18%2's,15. Hypersensitivity reactions to stainless steel wire have also been reported, but the precise clinical impact is not known 7. Little information is available about the pattern of maxillofacial fractures in Norwegian populations 14'2°'22. The aim of the present study was to analyze the frequency of maxillofacial fractures, and to relate them to socio-etiologic aspects. It was also intended to study the

localization of fractures, as well as the treatment procedures used, and to record the n u m b e r and nature of complications. The findings are related to a similar study from the same area carried out in the period 1974.914 . Material and methods

During a 2-year period, 1 July 1989-30 June 1991, a total of 169 patients with maxillofacial fractures were referred to the Department of Oral and Maxillofacial Surgery, Haukeland Hospital. The hospital is a regional center situated in the county of Hordaland, serving about 500 000 people in urban as well as rural areas of western Norway. The region is dominated by the city of Bergen, which has about 220 000 inhabitants, and the population distribution between urban and rural areas may be considered to be representative of the Norwegian population16. The collected data were based on information obtained from patient hospital records; we used a standardized form designed to reflect socioetiologic conditions, fracture pattern, and treatment variables. Pre- and postoperative radiographs were used to verify diagnosis and treatment, In discussion of treatment, the term "conservative" was used in cases where intermaxillary fixation without further intervention was utilized, or in cases of the nondisplaced fractures which were treated with a soft diet only. All records were reviewed by the same researcher. The data were processed by a statistical software system (SPSS, Inc., Chicago, USA). The chi-square test was used to test for statistical significance. A P value of

Key words: maxillofacial fractures; trauma; epidemiology; miniplates. Accepted for publication 3 September 1992

0.05 or less was considered to be statistically significant. Results Socio-eUologic data

The group comprised 133 males (79%) and 36 females (21%). The n u m b e r of patients was evenly distributed over the years 1989-91, and there was no statistical difference in frequency between the four seasons. Patients from the county of Hordaland, including Bergen city, predominated, and 27% of the patients were referred from the inner city of Bergen. The mean age of the patients was 31 years (range 4-96 years); most were aged 16-30 (Fig. 1). Occupational data showed that students represented 38% (Fig. 2). One-fifth of the patients were unemployed. Maxillofacial fractures occurred four times more frequently in factory and construction workers than in service and office workers, as estimated from official occupational statistics 16. Work-related jaw fractures affected only men. A b o u t one-third of the patients reported regular use of medication at the time of injury, and sedatives and hypnotic drugs were often used, even in the younger age groups. Twenty percent of the patients were reported to be allergic, of whom six patients gave a history of metal hypersensitivity (five nickel and one chromium).

Torgersen and Tornes

336 50

% OF PATIENTS I

40

t

~MALE E3FEMALE

..........................

"CONfi 3O WORK

2O

WIRE OSTEOI

SPORT

OTHER~ 0

0-15

16-30

31-45 46-60 AGE (YEARS)

0

>60

10

20 30 % OF PATIENTS

40

50

Fig. 3. Causes of maxillofacial fractures.

Information about hypersensitivity was missing in 19% of the patient records. Assault was the main cause of maxillofacial fractures (Fig. 3). Of the 82 victims of interpersonal violence, 10 were female. Mandibular body and angle t~ractures had a stronger association with interpersonal violence than did other etiologic factors ( P < 0.01). Alcohol abuse was part of the history in 28% of all patients, and in 84% of the assault victims. Hospitalization was required in 116 patients (69%), and the mean hospital stay was 5.4 d (range 1-24 d). Traffic accidents caused the longest hospitalization period (71% stayed more than 5 d). When miniplate treatment was used, 57% of the patients left the hospital within 4 d. No sick leave was recorded in 49% of the patients treated with miniplate osteosynthesis. Mean duration of sick leave after hospitalization for jaw fracture treatment was 22 d. Intermaxillary fixation during healing of jaw fractures increased the sick leave period significantly (P < 0.03).

body fractures were most common (Fig. 4). Thirteen percent suffered from a combination of condylar fracture and other maxillofacial fractures. The ratio between fractures of the maxilla and the mandible was 1:4.8. In the outpatient group (53 patients), condylar fractures represented 49% of the cases, of which 94% were unilateral. All but three fractures in outpatients were located in the mandible. In hospitalized patients, 79% of the fractures were found in the mandible, and 51% suffered from more than one fracture. Brain concussion was found in 21% of all patients; it was particularly related to traffic accidents and falls. Fractures of the teeth were recorded in 23% of the patients.

In the 169 patients, 231 maxillofacial fi'actures were recorded. Mandibular

Treatment and complications

Sixty-three percent of the patients received definitive treatment within 48 h, with a mean delay of 2.7 d in the population studied. Noncompression miniplate osteosynthesis was the most frequent treatment, followed by "conservative" treatment (Fig. 5). Treatment modalities under the category "other" in Fig. 5 include reposition of fractures of the zygoma with a bone-hook with-

MAND.EODY

STUDENTS TRANSPORT AND FACTORY

I

I

MAND'ANGLE~> :....> :.,..> :. > >...:. >.. ,:~iI UNEMPLOYED I

ASC.RAMUSMAXILLA

SERVICE AND OFFICE OTHER 0

~% OF PATIENTS lf7% OF FRACTURES

ZYGOMA 10

20 30 % OF PATIENTS

40

Fig. 2. Occupational data of patients with maxillofacial fractures.

0

10

20 %

30

10

20 30 40 % OF PATIENTS

50

Fig. 5. Treatment of maxillofacial fractures. "Conservative" includes observation and intermaxillary fixation alone.

Fig. 1. Age and sex distribution of 169 patients with maxillofacial fractures.

Fracture frequency and localization

0

40

Fig. 4. Frequency and localization of 231 maxillofacial fractures in 169 patients.

out a securing osteosynthesis. In one patient a skeletal head frame fixation was applied. In 86% of the patients treated with rigid fixation, one or two plates were used; the remainder received up to four plates. Stainless steel (29%) or titanium (71%) miniplates were applied. Intermaxillary fixation was always used to aid in the reposition and stabilization of the fragments during operation. Intermaxillary elastic bands were often used for a few days postoperatively to help to maintain proper occlusion. Open reduction was performed through an intraoral approach in 70% of the cases. The remainder were treated by either an extraoral or a combined intraoral-extraoral procedure. Postoperative complications were found in 11% of patients. Local infections occurred in seven patients (4%). These infections occurred 1-8 weeks after termination of the initial antibiotic treatment given at the first perioperative period, usually lasting 1 week. Diffuse pain was found in five patients. In two patients a miniplate became exposed in the oral cavity after fracture healing. Temporomandibular joint clicking was found in two patients, and another two patients experienced adverse reactions related to the use of stainless steel arch bars (aphthous ulcers and dermatitis). The skin reaction occurred temporarily in one patient with chromium hypersensitivity. None of the complications resulted in removal of osteosynthesis devices before fracture healing. Temporary occlusal instability during the first weeks after trauma was seen in 13 patients; however, normal occlusion was achieved with the use of elastic bands. Delayed miniplate osteosynthesis (more than 3 d), which was performed in 12 patients, showed no significant increase in complication rate. Patients who

Maxillofacial fractures in a Norwegian district smoked more than 10 cigarettes a day had a significantly increased complication rate ( P < 0.03); 71% experienced postoperative wound infections.

Discussion

Recent studies have shown an increase in the number of maxillofacial fractures~.6.19; however, others report jaw fractures to be levelling off 18. The present study shows that almost twice as many persons sustained a maxillofacial trauma as found in an earlier study from the same region 14, while the general population of the region has increased about 5% only. The male:female ratio of 3.7:1 agrees with other studies ~2'2~'22, and has not changed in the region 14. Persons aged 15-35 are usually overrepresented in the patient group sustaining maxillofacial trauma 1,6,12'~5'2°'22. Young people are most often involved in interpersonal violence and sports injuries, while falling accidents predominate in the older age group 2°. Fractures resulting from traffic accidents showed a relative decrease, as compared with 15 years ago 14. The introduction of compulsory car seat belts in 1979 seems to be the major contributing factor in the reduction in the number and severity of jaw fractures caused by traffic accidents 12,~9.The marked change in causation towards fighting, often related to alcohol abuse, as found in this study, is recognized by many authors ~2:8'2°, and may reflect increased social problems. The fact that many students are affected by jaw fractures reflects the age distribution in the material and the general population distribution in the region 16. The high number of unemployed people suffering from maxillofacial fractures coincides with the rising unemployment figures and social antagonism in the community1:9. The present study confirms that work accidents resulting in maxillofacial fractures are more frequent among factory and construction workers than service and office workers 9. Mandibular body fractures were most common, as was also found in the previous study from Hordaland County ~4. The present study supports the finding that mandibular body and angle fractures are frequently a result of interpersonal violence1; STROM18, however, found condylar fractures to have a strong association with falls and interpersonal violence. A relative reduction

in midface fractures was found, as compared with 15 years ago, and this may be explained by the marked reduction in traffic injuries in general 19. The combination of facial fractures and closed head injuries was frequently seen, as also noted by HAu~ et al. s. The criteria for hospitalization of patients and the average period of time before commencement of treatment have not changed during the past decade in our department. Stabilization with miniplates, with brief or no use of intermaxillary fixation, has probably contributed to earlier recovery from treatment and thereby caused the marked decrease in duration of hospital stayS,i 1,14. The reduced sick-leave period supports this opinion as welP 4. While internal fixation by miniplates was used in only one patient during the period 1974-9, miniplate osteosynthesis has become the standard procedure in our department, especially for mandibular fractures. Most operations were performed through an intraoral approach. The extraoral or combined intraoral~xtraoral procedure was mainly used when treating zygoma fractures, and when the intraoral approach failed to achieve ideal lines of osteosynthesis3. A "conservative" approach to jaw fractures in children is still preferred in our department. The use of stainless steel surgical arch bars or implant devices in patients with metal hypersensitivity may cause adverse reactions7. The introduction of titanium has reduced the use of stainless steel miniplates. Stainless steel miniplates or wires were routinely removed after healing of jaw fractures in our institution. The possible release of corrosion products from titanium ~3, has raised the question of whether routine removal of titanium implants should also be performed. A European study group on this subject (SORG) has suggested that nonfunctional implants should be removed tT. The present results regarding the complication rate agree with data presented by other authors 2,3,4:4'~5.When one considers complication rates, the observation period should be taken into account. Adverse effects such as loosening of screws or immunologic reactions may occur as a late complication, years after insertion4. In contrast to that of WIDMARK & KAHNBERG23, the present study does not support the finding of a higher infection rate in patients with delayed miniplate osteosynthesis. The relation-

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ship of smoking to impaired intraoral wound healing is in dispute 1°, but the present study supports such a relationship.

References

1. ADI M, OGDENGR, CHISHOLMDM. An analysis of mandibular fractures in Dundee, Scotland (1977 to 1985). Br J Oral Maxillofac Surg 1990: 28: 194-9. 2. CAWOODJI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985: 23: 77-91. 3. CHAMPY M, PAPE H-D, GERLACHKL, LODDEJR The Strasbourg miniplate osteosynthesis. In: KRfSGERE, SCHILLIW, WORTHINGTONP, eds.: Oral and maxillofacial traumatology, vol. 2, Chicago: Quintessence, 1986: 19-43. 4. CHRISTIANSEN K, HOLMES K, ZILKO PJ. Metal sensitivity causing loosened joint prostheses. Ann Rheum Dis 1980: 39: 476 80. 5. DODSON TB, PERROTT DH, KABAN LB, GORDON NC. Fixation of mandibular fractures: a comparative analysis of rigid internal fixation and standard fixation techniques. J Oral Maxillofac Surg 1990: 48: 362-6. 6. ERIKSSON L, WILLMAR K. Jaw fractures in Malta6 1952-62 and 1975 85. Swed Dent J 1987: 11: 31-6. 7. GUYURONB, LASA CI JR. Reaction to stainless steel wire following orthognathic surgery. Plast Reconstr Surg 1992: 89: 540-2. 8. HAUG RH, SAVAGEJD, LIKAVECMJ, CONFORTIPJ. A reviewof 100 closed head injuries associated with facial fractures. J Oral Maxillofac Surg 1992: 50:218 22. 9. IIZUKA T, RANDELL T, GOVEN O, LINDQVISTC. Maxillofacialfractures related to work accidents. J Craniomaxillofac Surg 1990: 18: 255-9. 10. JONESJK, TRIPLETTRG. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence and implications for patient care. J Oral Maxillofac Surg 1992: 50: 237-9. 11. KAHNBERG K-E. Conservative treatment of uncomplicated mandibular fractures. Swed Dent J 1981: 5: 15-20. 12. METZINGERSE, NAUGHTONMJ, HOWE RE, HOWARD PS. An epidemiologic study of maxillofacial trauma at Carraway Methodist Medical Center, a level I trauma center. Ala Med 1988: June: 23-31. 13. MOBERG L-E, NORDENRAMfi'k, KJELLMAN O. Metal release from plates used in jaw fracture treatment. A pilot study. Int J Oral Maxillofac Surg 1989: 18: 311-14. 14. OLSENH. En etterundersokelse av kjevefrakturer behandlet ved Kjevekirurgisk avde!ing, Haakeland Sykehus, Bergen, 1974-1979. Thesis, Bergen, 1987.

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15. SMITH WP. Delayed miniplate osteosynthesis for mandibular fractures. Br J Oral Maxillofac Surg 1991: 29: 73-6. 16. STATISTICALYEARBOOKOF NORWAY. Central Bureau of Statistics of Norway, OsloKongsvinger, 1979-91. 17. STRASBOURG OSTEOSYNTHESIS RESEARCH

GROUP, 3rd SORG Meeting, Volendam, 14-16 November 1991. 18. STRrM C. Criminal violence and maxillofacial injuries in Sweden. A retrospective epidemiological study on criminal violence and ensuing injuries. Thesis, Departments of Oral Surgery and Social and Forensic Psychiatry, Karolinska Institutet, Huddinge, Sweden, 1992.

19. TELFER MR, JONES GM, SHEPHERD JR Trends in the aetiology of maxillofacial fractures in the United Kingdom (1977-1987). Br J Oral Maxillofac Surg 1991: 29: 250-5. 20. TRUMPYIG. Voldens ansikter. Norge - et voldssamfunn? Tidsskr Nor Laegeforen 1992: 112: 3214. 21. gETTER JD, TOPAZIAN RG, GOLDBERG MH, SMITH DG. Facial fractures occurring in a medium-sized metropolitan area: recent trends. Int J Oral Maxillofac Surg 1991: 20: 214-16. 22. Voss R. The aetiology of jaw fractures in Norwegian patients. J Maxillofac Surg 1982: 10: 146-8.

23. WIDMARK G, KAHNBERG K-E. Use of miniplates in the treatment of jaw fractures. Swed Dent J 1991: 15: 265-70.

Address:

Sissel Torgersen, DDS Department of Dental Materials School of Dentistry ~rstadveien 17 N-5009 Bergen Norway