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Five-Year Retrospective Study of Mandibular Fractures in Freiburg, Germany: Incidence, Etiology, Treatment, and Complications
J Oral Maxillofac Surg 67:1251-1255, 2009
Five-Year Retrospective Study of Mandibular Fractures in Freiburg, Germany: Incidence, Etiology, Treatment, and Complications Kai-Hendrik Bormann, DDS,* Sarah Wild, DDS,† Nils-Claudius Gellrich, MD, DDS,‡ Horst Kokemüller, MD, DDS,§ Constantin Stühmer, MD, DDS,㛳 Rainer Schmelzeisen, MD, DDS,¶ and Ralf Schön, MD, DDS# Purpose: To evaluate current trends in maxillofacial trauma, a retrospective review of mandibular
fractures at a German university hospital was carried out. Patients and Methods: In this retrospective study, records of 444 patients with mandibular fractures between 2000 and 2005 at the Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany, were reviewed. A total of 444 patients presented with 696 mandibular fractures. Results: Three hundred twenty-nine (74%) of the fractures occurred in male and 115 (26%) in female patients (2.9:1). One hundred forty-two fractures (32%) resulted from road traffic accidents, 126 from fights (28%), and 116 from falls (26%). Forty-four fractures were caused by sport accidents (10%) and 16 by pathologic fractures (4%). The mandibular condyle area was the most common fracture site, with 291 fractures (42%), followed by 144 fractures of the symphyseal and parasymphyseal area (21%) and 141 angle fractures (20%). Combined fractures were found in nearly half of the cases. Five hundred seventy-nine (83%) of patients with mandibular fractures were treated by surgical intervention, 117 (17%) of patients conservatively. Regarding the surgical treatment, 561 (65%) miniplates, 247 (29%) locking plates, and 51 (6%) lag screws were used. Complications, such as postoperative infections, abscesses, and osteomyelitis appeared in 66 (9%) cases. Conclusion: We concluded that osteosynthesis of mandibular fractures by miniplates and locking plates are both reliable. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1251-1255, 2009 The etiology of facial trauma varies in different cultures and societies.1-11 The University of Freiburg is located in the southern part of Germany, surrounded by the Blackwood Forest, Switzerland, and France. In a university city like Freiburg with its young population, bicycling *Associate Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. †Private Practice, Zentrum für Zahnmedizin Dr. Schulz, Hannover, Germany. ‡Head Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. §Associate Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. 㛳Assistant, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. ¶Head Professor, Department of Oral and Maxillofacial Surgery University Hospital, Freiburg, Germany.
and mountain biking are very popular. To evaluate current trends in maxillofacial trauma at the University Hospital of Freiburg, Germany, we carried out a retrospective review of the treatment of mandibular fractures between 2000 and 2005. #Associate Professor, Department of Oral and Maxillofacial Surgery University Hospital, Freiburg, Germany. Address correspondence and reprint requests to Dr Bormann: Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6706-0016$36.00/0 doi:10.1016/j.joms.2008.09.022
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RETROSPECTIVE STUDY OF MANDIBULAR FRACTURES
Patients and Methods In a retrospective study, records of 444 patients with mandibular fractures between 2000 and 2005 at the Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany, were reviewed. Age, gender, cause of injury, location of fracture, type of treatment, and postoperative complications were recorded. Treatment was by open reduction by an intraoral or extraoral approach, and osteosynthesis with the AO/ASIF 2.0 titanium miniplate system, UniLOCK system, and lag srews in 579 of 696 mandibular fractures. One hundred seventeen fractures were treated by closed reduction and maxillomandibular fixation (MMF). The location of fractures was evaluated by x-rays, surgery, and doctor’s reports. The classification followed the report of the AO Foundation.12
Results Between 2000 and 2005, a total of 444 patients presented with 696 mandibular fractures at Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany. The rate of single and multiple fractures was balanced (221:223). The youngest patient was 10 years of age, the oldest patient 96 years of age. The average age was 37 years. Thirty-two percent were in the age group of 16 to 25 years, 23% in the group of 26 to 35 years, and 17% in the age group of 36 to 45 years (Fig 1). There was a male predominance (Fig. 2). One hundred forty-two fractures (32%) resulted from road traffic accidents and 126 from fights (28%), followed by 116 falls (26%), 44 because of sport accidents (10%), and 16 by pathologic fractures (4%). The road traffic accidents were caused by bicycles in 97 cases, car accidents in 32 cases, and motorbikes in 13 cases (Fig 3).
FIGURE 2. Mandibular fractures regarding age and gender. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
Interpersonal violence was most the common reason for mandibular fractures in the age group of 16 to 25 years, with a male predominance. In total, the ratio of male to female was 2.9:1. The 116 falls were comprised of accidents at home (n ⫽ 73) and at work (n ⫽ 26), syncopes (n ⫽ 8), epilepsy (n ⫽ 7), and suicides (n ⫽ 2). Soccer, with 26 patients (59%), was the main cause of all sports-related injuries, and all soccer-related fractures were presented in male patients. Six horse riding accidents (14%) appeared only in female patients. The remaining sports injuries were caused by blading (n ⫽ 4), handball (n ⫽ 3), skiing (n ⫽ 2), ice hockey (n ⫽ 2), and boxing (n ⫽ 1). In 49% of all pathologic fractures, removal of the third molar was causal for fracture, followed by oral cancer (38%) and other reasons, for example, osteomyelitis. The condyle area was the most common site of mandibular fractures in 291 cases (42%). One hundred forty-four (21%) fractures of symphysis or parasymphysis, 141 (20%) angle fractures, 101 (15%) frac-
FIGURE 1. Distribution by age.
FIGURE 3. Cause of traffic accidents.
Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
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FIGURE 4. Localization of mandibular fractures. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
tures of horizontal ramus, 17 (2%) fractures of the ramus, and 2 (0.3%) coronoid fractures were noted (Fig 4). Five hundred seventy-nine (83%) fractures were treated by open reduction via an intraoral (n ⫽ 558) or extraoral (n ⫽ 21) approach; 117 (17%) received a closed reduction. In total, 854 osteosynthesis were done. Miniplates were used in 561 (65%) cases, UniLOCK plates in 247 (29%), and lag screws in 51 (6%) cases (Fig 5). Complications were found in 66 (15%) of 444 patients. Forty-five (68%) of the 66 patients presented an infection or dehiscency; in 15 (23%) patients early removal of the plate within 6 months of operation was performed.
Discussion Four hundred forty-four patients with mandibular fractures were recorded in a retrospective study between 2000 and 2005. The youngest patient was 10 years of age, the oldest patient 96 years of age. The average age was 37 years. Twenty-one percent of patients were in the age group 16 to 25 years. In accordance with our findings, Ferreira et al13 found a percentage of 47 of patients between 16 to 18 years.
FIGURE 5. Open reduction with different osteosynthesis. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
FIGURE 6. Incidents of fractures. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
The high incidence of mandibular fractures in young patients and the male:female ratio of 2.9:1 was in agreement with other reports.2,3,6,8,14,15 Comparing studies in the present time, a significant increase of male patients with mandibular fractures was found. Otten14 and Esser16 figured a ratio of 1:2.8. Road traffic accidents and fights were the leading causes of mandibular fractures, followed by falls. Bicycle accidents were the most common cause of all road traffic accidents (Fig 6). This may be related to the fact that Freiburg is a small university city with a young population. In contrast to the Freiburg findings, the incidence of bicycle-related injuries in larger German cities, such as Hamburg and Bochum, was reduced. Car and bike accidents were equally common.17,18 Falls and sports-related accidents also appear more common in larger cities.3,6,8,11,19,20 In the literature, fights are reported to be the most common cause of mandibular fractures in rural and farming population and in various ethnic groups.1,2,3,6,15 In comparison to this situation, fewer acts of violence in Japan were observed, which is because of East-Asian mentality21 (Table 1). The site of fracture is related to the cause. The condyle area was the main site of fracture, corresponding with bicycle accidents as the main cause of injury. During bicycle-related injuries, a fall on the chin is a common cause of mandibular trauma, resulting in a high incidence of condyle fractures.22 Another common fracture site was the combined angle and horinzontal ramus, and the angle and parasymphysal region, a typical cause by fist fighting. The results of Ellis et al3 indicated that condylar fractures were much more common in motor vehicle accidents (36.1%) and falls (36.3%) than in alleged assaults (24.3%) whereas a much higher percentage of angle fractures (30.6%) occurred in alleged assault victims
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Table 1. CAUSE OF INJURY COMPARED WITH RESULTS REPORTED ELSEWHERE
Road traffic accidents Fights Falls Sport accidents Other
Freiburg, Germany n ⫽ 444
Townsville, Australia39 n ⫽ 114
Adelaide, Australia5 n ⫽ 324
Glasgow, UK7 n ⫽ 2173
Iowa, USA28 n ⫽ 580
Sapporo, Japan37 n ⫽ 477
32 28 26 10 4
10 83 3 2 3
21 53 8 13 5
15 55 21 3 5
48 34 8 2 7
38 15 25 16 6
Figures are no. (%). Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
than in falls (17.2%) and motor vehicle accidents (10.9%). In our report, 10% of sport accidents are the cause of mandibular fractures. Comparing the study of Tanaka et al,23 they figured 10.4% of sport accidents were related to maxillofacial fractures. In contrast to these findings, Emshoff et al24 reported a total of 31.5% in sports-related mandibular fractures. Fractures of the condyle area were a result of direct force effort but also of indirect force effort. Considering the proportional change in sports accidents, there was a significant increase from 5% to 8.3% within 10 years.25 Being put forward as an argument, in other reports26 the increase in leisure-time sports leads to a growing number of leisure and sports injuries. Fractures of the mandibular angle have the highest incidence of complications.27-34 In the present study, 43% of the fractures were at the mandibular angle. The number of complications in our study (9.5%) was similar to data from other publications of miniplate fixation.35 Complications, such as infections or osteomyelitis, are more common in patients who have sustained multiple injuries and comminuted fractures, which occur in high velocity accidents rather than in altercations.8 For comminuted fractures more rigid fixation is indicated. Open reduction and osteosynthesis with the 2.0 miniplates became the treatment of choice. Comparing a study of Göhring36 in 1991, only 11% miniplates were used, whereas 51% miniplates were used in 2005.25 The rate of complications has decreased. In 3% of cases, having a total of 579 mandibular fractures with open reduction, an extraoral approach was chosen. In these cases, bigger plates (reconstruction plates) were used because the kind of fracture was more difficult. Comparing to a 2006 study in Freiburg, a higher percentage is obvious. An extraoral approach was found in 9% of cases.37 Five hundred fifty-eight of 579 (96%) fractures with open reduction in this series were treated with
miniplates transorally to avoid extraoral scars and damage to the facial nerve.9,34,38 In contrast to our findings with a complication rate of 9%, postoperative complications have been reported in 25% to 29% of cases having miniplates.28,39 Closed reduction is only suitable for selected patients; as in noncompliant patients, the postoperative management may be difficult and the time in the hospital may be longer.3,5,32 Comparing results for treatment of mandibular fractures in the literature, 11% in 199139 and 51% in 200525 (65% miniplates) have been found. There is a trend to smaller osteosynthesis. We concluded that osteosynthesis of mandibular fractures by the AO/ASIF titanium system is reliable.
References 1. Akama MK, Chindia ML, Ndungu FL: Occurence pattern of mandibular fractures at Kisii District Hospital, Kenya. East Afr Med J 70:732, 1993 2. Edwards TJ, David JD, Simpson DA, et al: Patterns of mandibular fractures in Adelaide, South Australia. Aust NZ J Surg 64:307, 1994 3. Ellis E, Moos KF, El-Attar A: Ten years of mandibular fractures: An analysis of 2,137 cases. Oral Med Oral Pathol Oral Surg 59:120, 1985 4. Fridrich KL, Pena-Velasco G, Olson RA: Changing trends with mandibular fractures. A review of 1,067 cases. J Oral Maxillofac Surg 50:586, 1992 5. Iizuka T, Lindquist C: Rigid internal fixation of mandibular fractures. An analysis of 270 fractures treated using the AO/ ASIF method. Int J Oral Maxillofac Surg 21:65, 1992 6. Melmed EP, Koonin AJ: Fractures of the mandible. Plastic Recontr Surg 56:323, 1975 7. Oikarinen K, Ignatius E, Kauppi, et al: Mandibular fractures in Northern Finland in the 1980s—A 10 year study. Br J Oral Maxillofac Surg 31:23, 1993 8. Olson RA, Fonseca RJ, Zeitler DL, et al: Fractures of the mandible. J Oral Maxillofac Surg 40:23, 1982 9. Spiessel B: Internal Fixation of the Mandible. A Manual of AO/ASIF Principles. Berlin, Springer-Verlag, 1989, p 151 10. Starkhammer H, Olofsson J: Facial fractures: A review of 922 cases with special reference to incidence and aetiology. Clin Otolaryngol 7:405, 1982 11. Tanaka N, Tomitsuka K, Shionoya K, et al: Aetiology of maxillofacial fracture. Br J Oral Maxillofac Surg 32:19, 1994 12. Campell RL, Shamaskin RG, Harkins SW: Assessment of recovery from injury to inferior alveolar and mental nerves. Oral Surg Oral Med Oral Pathol 64:519, 1987
BORMANN ET AL 13. Ferreira PC, Amarante JM, Silva PN, et al: Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 115:1500, 2005 14. Otten J-E, Rose E, Rückauer K, et al: Verletzungsmuster bei Patienten mit Gesichtsschädelfrakturen. Dtsch Z Mund Kiefer Gesichts Chir 19:204, 1995 15. Bernstein L, McClurg FL: Mandibular fractures: A review of 156 consecutive cases. Laryngoscope 87:957, 1977 16. Esser NC: Katamnestische Untersuchung von Unterkieferfrakturen in den Jahren 1993 bis 1997. Med. Dissertation Universität Tübingen, 2003 17. Kolle GC: Vergleich chirurgischer und konservativer Behandlung von Unterkieferfrakturen im Zentralkrankenhaus SanktJürgen-Strasse, Bremen, von 1985 bis 1997. Med. Dissertation Ruhr Universität Bochum, 2002 18. Meyer U, Benthaus S, Du Chesne A, et al: Untersuchung von Gesichtsschädelfrakturen unter ätiologischen und rechtsrelevanten Gesichtspunkten. Mund Kiefer Gesichtschir 3:152, 1999 19. Lim LH, Moore MH, Trott JA, et al: Sports related facial fractures: A review of 127 patients. Aust NZ J Surg 63:84, 1993 20. Vetter JD, Topazian RG, Goldberg MH, et al: Facial fractures occurring in a medium-sized metropolian area: Recent trends. Int J Oral Maxillofac Surg 20:214, 1991 21. Iida S, Kogo M, Sugiura T, et al: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30:286, 2001 22. Tuncali D, Barutcu AY, Aslan G: The relationship between the fracture site and aetiology in mandibular fractures. Kulac Burun Bogaz Ihtis Derg 14:25, 2005 23. Tanaka N, Hayashi S, Amagasa T, et al: Maxillofacial fractures sustained during sports. J Oral Maxillofac Surg 54:715, 1996 24. Emshoff R, Schöning H, Röthler G, et al: Trends in the incidence and cause of sport-related mandibular fractures: a retrospective analysis. J Oral Maxillofac Surg 57:585, 1997 25. Ramm S: Retrospektive Untersuchung von operativ versorgten Unterkieferfrakturen an der Nordwestdeutschen Kieferklinik von 1997 bis 2000. Med. Dissertation Nordwestdeutsch Kieferklinik Hamburg, 2002 26. Schilli W, Schwenzer N: Sportverletzungen des Kopfes, in Weller S, Hierholzer G (eds): Traumatologie aktuell, Bd. 11. New York, Georg Thieme Verlag, 1993
1255 27. El-Degwi A, Mathog RH: Mandible fractures—Medical and economic considerations. Otolaryngol Head Neck Surg 108:213, 1993 28. Ellis E, Karas N: Treatment of mandibular angle fractures using two mini dynamic compression plates. J Oral Maxillofac Surg 50:958, 1992 29. James RB, Fredrickson C, Kent JN: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981 30. Mathog RH, Boies LR: Non union of the mandible. Laryngoscope 86:908, 1976 31. Passeri LA, Ellis E, Sinn DP: Complications of nonrigid fixation of mandibular angle fractures. J Oral Maxillofac Surg 51:382, 1993 32. Stone IE, Dodson TB, Bays RA: Risk factures for infection following operative treatment of mandibular fractures: Multivariate analysis. Plas Reconstr Surg 91:64, 1993 33. Tuovinen V, Norholt SE, Sindet-Pedersen S, et al: A retrospective analysis of 279 patients with isolated mandibular fractures treated with Titanium miniplates. J Oral Maxillofac Surg 52: 931, 1994 34. Lindquist C, Kontio R, Pihakari A, et al: Rigid internal fixation of mandibular fractures. An analysis of 45 patients treated according to the ASIF method. Int J Oral Maxillofac Surg 15: 657, 1986 35. Lamphier J, Ziccardi V, Ruvo A, et al: Complication of mandibular fractures in an urban teaching center. J Oral Maxillofac Surg 61:745, 2003 36. Göhring T: Retrospektive Studie an 336 in der Nordwestdeutschen Kieferklinik chirurgisch versorgten Unterkieferfrakturpatienten. Med. Dissertation Universität Hamburg, 1991 37. Hauptmann S: Behandlung von Unterkieferfrakturen mit Osteosyntheseplatten des Unilock-2.0 Systems. Med. Dissertation Universität Freiburg im Breisgau, 2006 38. Raveh J, Vuillemin T, Lädrach K, et al: Plate osteosynthesis of 367 mandibular fractures. J Craniomaxillofac Surg 15:244, 1987 39. Johansson B, Krekmanov L, Thomsson M: Miniplate osteosynthesis of infected mandibular fractures. J Craniomaxillofac Surg 16:22, 1988
Five-Year Retrospective Study of Mandibular Fractures in Freiburg, Germany: Incidence, Etiology, Treatment, and Complications Kai-Hendrik Bormann, DDS,* Sarah Wild, DDS,† Nils-Claudius Gellrich, MD, DDS,‡ Horst Kokemüller, MD, DDS,§ Constantin Stühmer, MD, DDS,㛳 Rainer Schmelzeisen, MD, DDS,¶ and Ralf Schön, MD, DDS# Purpose: To evaluate current trends in maxillofacial trauma, a retrospective review of mandibular
fractures at a German university hospital was carried out. Patients and Methods: In this retrospective study, records of 444 patients with mandibular fractures between 2000 and 2005 at the Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany, were reviewed. A total of 444 patients presented with 696 mandibular fractures. Results: Three hundred twenty-nine (74%) of the fractures occurred in male and 115 (26%) in female patients (2.9:1). One hundred forty-two fractures (32%) resulted from road traffic accidents, 126 from fights (28%), and 116 from falls (26%). Forty-four fractures were caused by sport accidents (10%) and 16 by pathologic fractures (4%). The mandibular condyle area was the most common fracture site, with 291 fractures (42%), followed by 144 fractures of the symphyseal and parasymphyseal area (21%) and 141 angle fractures (20%). Combined fractures were found in nearly half of the cases. Five hundred seventy-nine (83%) of patients with mandibular fractures were treated by surgical intervention, 117 (17%) of patients conservatively. Regarding the surgical treatment, 561 (65%) miniplates, 247 (29%) locking plates, and 51 (6%) lag screws were used. Complications, such as postoperative infections, abscesses, and osteomyelitis appeared in 66 (9%) cases. Conclusion: We concluded that osteosynthesis of mandibular fractures by miniplates and locking plates are both reliable. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1251-1255, 2009 The etiology of facial trauma varies in different cultures and societies.1-11 The University of Freiburg is located in the southern part of Germany, surrounded by the Blackwood Forest, Switzerland, and France. In a university city like Freiburg with its young population, bicycling *Associate Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. †Private Practice, Zentrum für Zahnmedizin Dr. Schulz, Hannover, Germany. ‡Head Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. §Associate Professor, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. 㛳Assistant, Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. ¶Head Professor, Department of Oral and Maxillofacial Surgery University Hospital, Freiburg, Germany.
and mountain biking are very popular. To evaluate current trends in maxillofacial trauma at the University Hospital of Freiburg, Germany, we carried out a retrospective review of the treatment of mandibular fractures between 2000 and 2005. #Associate Professor, Department of Oral and Maxillofacial Surgery University Hospital, Freiburg, Germany. Address correspondence and reprint requests to Dr Bormann: Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6706-0016$36.00/0 doi:10.1016/j.joms.2008.09.022
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Patients and Methods In a retrospective study, records of 444 patients with mandibular fractures between 2000 and 2005 at the Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany, were reviewed. Age, gender, cause of injury, location of fracture, type of treatment, and postoperative complications were recorded. Treatment was by open reduction by an intraoral or extraoral approach, and osteosynthesis with the AO/ASIF 2.0 titanium miniplate system, UniLOCK system, and lag srews in 579 of 696 mandibular fractures. One hundred seventeen fractures were treated by closed reduction and maxillomandibular fixation (MMF). The location of fractures was evaluated by x-rays, surgery, and doctor’s reports. The classification followed the report of the AO Foundation.12
Results Between 2000 and 2005, a total of 444 patients presented with 696 mandibular fractures at Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany. The rate of single and multiple fractures was balanced (221:223). The youngest patient was 10 years of age, the oldest patient 96 years of age. The average age was 37 years. Thirty-two percent were in the age group of 16 to 25 years, 23% in the group of 26 to 35 years, and 17% in the age group of 36 to 45 years (Fig 1). There was a male predominance (Fig. 2). One hundred forty-two fractures (32%) resulted from road traffic accidents and 126 from fights (28%), followed by 116 falls (26%), 44 because of sport accidents (10%), and 16 by pathologic fractures (4%). The road traffic accidents were caused by bicycles in 97 cases, car accidents in 32 cases, and motorbikes in 13 cases (Fig 3).
FIGURE 2. Mandibular fractures regarding age and gender. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
Interpersonal violence was most the common reason for mandibular fractures in the age group of 16 to 25 years, with a male predominance. In total, the ratio of male to female was 2.9:1. The 116 falls were comprised of accidents at home (n ⫽ 73) and at work (n ⫽ 26), syncopes (n ⫽ 8), epilepsy (n ⫽ 7), and suicides (n ⫽ 2). Soccer, with 26 patients (59%), was the main cause of all sports-related injuries, and all soccer-related fractures were presented in male patients. Six horse riding accidents (14%) appeared only in female patients. The remaining sports injuries were caused by blading (n ⫽ 4), handball (n ⫽ 3), skiing (n ⫽ 2), ice hockey (n ⫽ 2), and boxing (n ⫽ 1). In 49% of all pathologic fractures, removal of the third molar was causal for fracture, followed by oral cancer (38%) and other reasons, for example, osteomyelitis. The condyle area was the most common site of mandibular fractures in 291 cases (42%). One hundred forty-four (21%) fractures of symphysis or parasymphysis, 141 (20%) angle fractures, 101 (15%) frac-
FIGURE 1. Distribution by age.
FIGURE 3. Cause of traffic accidents.
Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
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FIGURE 4. Localization of mandibular fractures. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
tures of horizontal ramus, 17 (2%) fractures of the ramus, and 2 (0.3%) coronoid fractures were noted (Fig 4). Five hundred seventy-nine (83%) fractures were treated by open reduction via an intraoral (n ⫽ 558) or extraoral (n ⫽ 21) approach; 117 (17%) received a closed reduction. In total, 854 osteosynthesis were done. Miniplates were used in 561 (65%) cases, UniLOCK plates in 247 (29%), and lag screws in 51 (6%) cases (Fig 5). Complications were found in 66 (15%) of 444 patients. Forty-five (68%) of the 66 patients presented an infection or dehiscency; in 15 (23%) patients early removal of the plate within 6 months of operation was performed.
Discussion Four hundred forty-four patients with mandibular fractures were recorded in a retrospective study between 2000 and 2005. The youngest patient was 10 years of age, the oldest patient 96 years of age. The average age was 37 years. Twenty-one percent of patients were in the age group 16 to 25 years. In accordance with our findings, Ferreira et al13 found a percentage of 47 of patients between 16 to 18 years.
FIGURE 5. Open reduction with different osteosynthesis. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
FIGURE 6. Incidents of fractures. Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
The high incidence of mandibular fractures in young patients and the male:female ratio of 2.9:1 was in agreement with other reports.2,3,6,8,14,15 Comparing studies in the present time, a significant increase of male patients with mandibular fractures was found. Otten14 and Esser16 figured a ratio of 1:2.8. Road traffic accidents and fights were the leading causes of mandibular fractures, followed by falls. Bicycle accidents were the most common cause of all road traffic accidents (Fig 6). This may be related to the fact that Freiburg is a small university city with a young population. In contrast to the Freiburg findings, the incidence of bicycle-related injuries in larger German cities, such as Hamburg and Bochum, was reduced. Car and bike accidents were equally common.17,18 Falls and sports-related accidents also appear more common in larger cities.3,6,8,11,19,20 In the literature, fights are reported to be the most common cause of mandibular fractures in rural and farming population and in various ethnic groups.1,2,3,6,15 In comparison to this situation, fewer acts of violence in Japan were observed, which is because of East-Asian mentality21 (Table 1). The site of fracture is related to the cause. The condyle area was the main site of fracture, corresponding with bicycle accidents as the main cause of injury. During bicycle-related injuries, a fall on the chin is a common cause of mandibular trauma, resulting in a high incidence of condyle fractures.22 Another common fracture site was the combined angle and horinzontal ramus, and the angle and parasymphysal region, a typical cause by fist fighting. The results of Ellis et al3 indicated that condylar fractures were much more common in motor vehicle accidents (36.1%) and falls (36.3%) than in alleged assaults (24.3%) whereas a much higher percentage of angle fractures (30.6%) occurred in alleged assault victims
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RETROSPECTIVE STUDY OF MANDIBULAR FRACTURES
Table 1. CAUSE OF INJURY COMPARED WITH RESULTS REPORTED ELSEWHERE
Road traffic accidents Fights Falls Sport accidents Other
Freiburg, Germany n ⫽ 444
Townsville, Australia39 n ⫽ 114
Adelaide, Australia5 n ⫽ 324
Glasgow, UK7 n ⫽ 2173
Iowa, USA28 n ⫽ 580
Sapporo, Japan37 n ⫽ 477
32 28 26 10 4
10 83 3 2 3
21 53 8 13 5
15 55 21 3 5
48 34 8 2 7
38 15 25 16 6
Figures are no. (%). Bormann et al. Retrospective Study of Mandibular Fractures. J Oral Maxillofac Surg 2009.
than in falls (17.2%) and motor vehicle accidents (10.9%). In our report, 10% of sport accidents are the cause of mandibular fractures. Comparing the study of Tanaka et al,23 they figured 10.4% of sport accidents were related to maxillofacial fractures. In contrast to these findings, Emshoff et al24 reported a total of 31.5% in sports-related mandibular fractures. Fractures of the condyle area were a result of direct force effort but also of indirect force effort. Considering the proportional change in sports accidents, there was a significant increase from 5% to 8.3% within 10 years.25 Being put forward as an argument, in other reports26 the increase in leisure-time sports leads to a growing number of leisure and sports injuries. Fractures of the mandibular angle have the highest incidence of complications.27-34 In the present study, 43% of the fractures were at the mandibular angle. The number of complications in our study (9.5%) was similar to data from other publications of miniplate fixation.35 Complications, such as infections or osteomyelitis, are more common in patients who have sustained multiple injuries and comminuted fractures, which occur in high velocity accidents rather than in altercations.8 For comminuted fractures more rigid fixation is indicated. Open reduction and osteosynthesis with the 2.0 miniplates became the treatment of choice. Comparing a study of Göhring36 in 1991, only 11% miniplates were used, whereas 51% miniplates were used in 2005.25 The rate of complications has decreased. In 3% of cases, having a total of 579 mandibular fractures with open reduction, an extraoral approach was chosen. In these cases, bigger plates (reconstruction plates) were used because the kind of fracture was more difficult. Comparing to a 2006 study in Freiburg, a higher percentage is obvious. An extraoral approach was found in 9% of cases.37 Five hundred fifty-eight of 579 (96%) fractures with open reduction in this series were treated with
miniplates transorally to avoid extraoral scars and damage to the facial nerve.9,34,38 In contrast to our findings with a complication rate of 9%, postoperative complications have been reported in 25% to 29% of cases having miniplates.28,39 Closed reduction is only suitable for selected patients; as in noncompliant patients, the postoperative management may be difficult and the time in the hospital may be longer.3,5,32 Comparing results for treatment of mandibular fractures in the literature, 11% in 199139 and 51% in 200525 (65% miniplates) have been found. There is a trend to smaller osteosynthesis. We concluded that osteosynthesis of mandibular fractures by the AO/ASIF titanium system is reliable.
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