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Trends in the incidence and cause of sport-related mandibular fractures: A retrospective analysis
J Oral Maxlllofac Surg 55’585-592, 1997
Trends in the Incidence and Cause of Sport-Related Mandibular Fractures: A Retrospective Analysis RijDlGER EMSHOFF, MD, DMD,* HARALD SCHONING, MD, DMD,t GABRIEL RijTHLER, MD, DMD,$ AND ERNST WALDHART, MD, DMD§ Purpose: This study assessed changes in the incidence and causes of mandibular fractures occurring in Innsbruck, Austria between 1984 and 1993. Patients and Methods: Records from 712 patients sustaining 982 mandibular fractures were reviewed and analyzed according to age, sex, date of fracture, place of trauma, cause, anatomic site of fracture, and associated orofacial and craniocerebral injuries. Results: Sports were the most common cause of mandibular fractures, accounting for 31.5% of the entire sample, followed by road traffic accidents (27.2%) and falls (20.8%). The yearly distribution of sport-related mandibular fractures showed an increase from 28.6% in 1984 to 1988 to 34.5% in 1989 to 1993. The major causative factor in sports-related mandibular fractures was skiing (55.3%), whereas cycling and soccer accounted for 25.4% and 8.9%, respectively. Significant changes in the occurrence of cycling-related mandibular fractures were observed, with an increase of 19.3% from 1984 to 1988 to 1989 to 1993, whereas skiing-related mandibular fractures showed a decrease of similar magnitude (19.5%). Sex distribution showed a male-to-female ratio of 2.5:1, with the percentage of females involved increasing. In cases of cycling-related accidents, there was a considerable prevalence of associated injuries (133.3 injuries per 100 mandibular fractures), with significantly higher rates of facial lacerations (73.2), tooth fractures (39), tooth luxations (24.4) and orbital fractures (3.7) than in the case of skiing-related injuries, whereas in patients sustaining mandibular fractures caused by soccer, mucosal lacerations, tooth luxations, and cerebral concussions were the only associated injuries found. Conc/usions: The results of this study indicate a considerable change in the cause of mandibular fractures, showing that spotting injuries are becoming increasingly common. The high incidence of associated maxillofacial injuries in patients involved in skiing and cycling accidents may suggest an increasing need for preventive and protective measures.
Changing trends in the cause and number of facial injuries are important for developing recommendations for preventive measures and requirements in oral and maxillofacial surgery training programs. Studies from several countries describe traffic accidents, assaults, and falls as the most frequent causes of maxillofacial fractures. According to the investigations of Voss’ and Linn et al,’ sports-related injuries seem to be increasingly implicated in the causes of maxillofacial injuries. To evaluate trends in the occurrence of sports-related
Received from the Department of Oral and Maxlllofacial Surgery, University of Innsbruck, Austna. * Resident. f Resident. f Associate Professor. 5 Professor and Head. Address correspondence and reprint requests to Dr Emshoff: Hohenstral3e 5, A-6020 Innsbruck. Austria. 0 1997 American
Association
of Oral and Maxillofacial
Surgeons
0278-2391/97/5506-0009$3.00/O
585
586
70
TRENDS IN SPORT-RELATED Number of Patients
_-_-
---
___.- _._.____
MANDIBULAR
FRACTURES
-._ _
60 50 40 FIGURE 1. Age and sex distribution of patients with mandibular fractures.
30 20 10 o-9
IO-19
29-29
30-39
40-49
50-59
60-69
70-79
80-89
Age Group Male OFemale
to sports (31.5%). The patients with sports-related mandibular fractures ranged in age from 4 to 75 years, with 38.4% of the cases occurring between the ages of 10 and 29 years. The highest incidence was found in the 20- to 29-year age-group and the lowest in the 70- to 79-year age-group (Fig 1). Seventy-four percent of all fractures occurred in men and boys, and 26% occurred in women and girls, giving a male-to-female ratio of 2.5: 1. There was an increase in the percentage of females from 24.8% in 1984 to 1988 to 32.3% in 1989 to 1993.
facial trauma, a retrospective analysis of mandibular fractures treated at the Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria, during the years 1984 to 1993 was undertaken. Materials
and Methods
The records of all patients sustaining mandibular fractures from January 1984 to December 1993 were evaluated for the following data: age, sex, date of fracture, place of trauma, cause, anatomic site of fracture, and associated maxillofacial and non-maxillofacial injuries.
YEARLY AND MONTHLY DISTRIBUTIONOF MANDIBULARFRACTURES
Results
A yearly comparison of the number of patients with sports-related fractures compared with the total number of patients with fractures showed an uneven distribution over the lo-year period (Fig 2). A minimum of
In the lo-year period of this study, there were 712 patients with mandibular fractures, 224 of whom had suffered at least one mandibular fracture attributable
In_
Number of Patients
80 FIGURE 2. Yearly distribution of sports-related mandibular fractures m relation to the total number of patients with mandibular fractures.
60 40 20
1993
1992
1991
1990
1989
1988 Year
Sport-Related
-Total
1987
1986
1985
1984
EMSHOFF
587
ET AL
1988 - 1984
1993 - 1989 65.7%
d
FIGURE 3. Frequency of causes of sports-related mandibular fractures for the years 1984 to 1988 and 1989 to 1993.
FQSkiing
BXycling
BlSoccer
ElParagliding
BlGolf
LB Ice Hockey EYEI Boxing
25% sports-related fractures occurred in 1990, and a maximum of 45% occurred in 1991. There was an increase from 28.6% sports-related fractures in 1984 to 1988 to 34.5% in 1989 to 1993. Although the percentage of mandibular fractures caused by cycling increased from 15.2% in 1984 to 1988 to 34.5% in 1989 to 1993, the percentage of mandibular fractures related to skiing decreased from 65.7% in 1984 to 1988 to 46.2% in 1989 to 1993. The yearly frequency of soccer-related mandibular fractures showed an average percentage of 10.1% in 1989 to 1993 and 7.6% in 1984 to 1988 (Fig 3). The incidence of sports-related mandibular fractures correlated significantly with certain months. December, January, February, and March collectively accounted for the highest percentage (56.6%) of all fractures, and May, October, and November accounted for the lowest (11.5%). Skiing was found to be the most
FBSledding ElMountaineering
common cause during the period November to April (90.9%), whereas injury due to cycling was the prevalent cause of mandibular fractures during the period May to October (73.8%). The distribution of soccerrelated mandibular fractures was uneven from month to month, with an average of 9.9% during the period January to December (Fig 4). CAUSES OF MANDIBULAR
FRACTURES
Of the 712 patients with mandibular fractures occurring in the period 1984 to 1993, sports accidents were the most common cause, accounting for 31.5%. Road traffic accidents constituted 27.2%; falls, 20.8%; and assaults, 12.5%, and the remaining 8% were related to other causes. The major causative factor in sports-related mandib-
Number of Patients 35 30
FIGURE 4. Monthly distribution of sports-related mandibular fractures.
SkiingW Cycling&I SoccerR
Jan 31 1 0
Feb 28 0 0
Mar
Apr
28 0 1
7 3 2
May 1 7 2
Jun 1 11 5
Month
Jul 0 l2,8 2
Aug 2 2
Sept 1 9 3
Ott 3 3 1
1 Nov 5 2 2
Dee 17 1 0
TRENDS IN SPORT-RELATED
588
MANDIBULAR
FRACTURES
Skiing Male El Female
Soccer 100%
60%
Mountaineering
Sledding
25%
30% 75%
70%
100% Golf
Boxing 100%
Paragliding
100%
Ice Hockey 100%
FIGURE 5. Sex distribution of sports-related mandibular fractures according to the respective cause.
ular fractures was skiing, representing 55.3% of the entire sample. The second most common cause was cycling (25.4%), followed by soccer accidents (8.9%). The causes of the remaining fractures were classified as sledding (4.4%), mountaineering (3.6%), paragliding (0.9%), boxing (OS%), golf (0.5%), and ice hockey (OS%). Of the patients involved in sports-related man~bul~ fractures, 71% were men or boys and 29% women or girls. Figure 5 shows the sex distribution with respect to the causative groups. Of the patients sustaining mandibular fractures att~butable to skiing, 70% were men or boys and 30% were woman or girls. A total of 66.9% of these patients were younger than 30 years of age, whereas 41.4% of the injuries occurred in the 20- to 2Pyears age-group. Most patients involved in bicycle accidents were men or boys, accounting for 60%, whereas women or girls accounted for 40% of the injuries. A total of 50.9% of the cases involved were patients younger than 20 years of age, and 14. I % of the accidents occurred in the 0- to 9-year age-group. The patients involved in soccer accidents were solely
young males. Eighty percent of them were younger than age 30 years. Sledding and mountaineering showed a male predominance of 70% and 75%, respectively, whereas only male patients were involved in injuries caused by p~agliding, boxing, golf, and ice hockey. ANATOMIC DISTRIBUTIONOF MANDIBULAR FRACTURES
There were 327 sports-related mandibular fractures in the 224 patients, averaging 1.5 fractures per mandible. Of these, 34.9% involved the subcondylar area, 16.8% the symphysis area (defined as the region between the canines), and 18% the anterior body. Angle fractures accounted for 13.8% and posterior body fractures for 5.2%. Fractures of the ramus, the condyle, and the coronoid occurred in 5.2%, 4.9%, and 0.3% of the total, respectively. Figure 6 shows the variations in the number of m~dibul~ fractures according to the anatomic site and the causes-skiing, cycling, and soccer.
589
EMSHOFF ET AL Number of Mandibular
Fractures
60 50 40 30
FIGURE 6. Anatomic distribution of mandibular fractures caused by skiing, cycling, and soccer accidents.
20
10 0 Skiing= CyclingE Soccer=
Symphysis 35 11 5
Ant. Body 39 11 5
Post. Body 12 4 1
Angie 29 5 7
Ramus 9 3 2
Location of Mandibular
The subcondylar area was the most common site of fractures associatedwith skiing injuries (32.8%) (Fig 7A), followed by fractures of the anterior body (21%) and the symphyseal area (18.8%). Fractures of the angle and the posterior body showed an incidence of 15.6% and 6.5%, respectively, whereas ramus (4.8%) and condylar fractures (3.X%) occurred lessfrequently. An analysis of cycling accidents (Fig 7B) showed significantly fewer incidents of anterior body (13.4%) and angle fractures (6.1%), whereas subcondylar (50%) and condylar fractures (8.5%) were more frequent than in skiing injuries. Symphysis fractures were diagnosed in 13.4% of the sample, whereas fractures of the posterior body and the ramus constituted 4.9% and 3.7%, respectively. There were no fractures in the coronoid region. The most common site of mandibular fractures resulting from soccer injuries (Fig 7C) was the subcondylar area (28.6%), with a frequency similar to that of skiing injuries. Fractures of the symphysis area (17.9%), the anterior body (17.9%), and the posterior body (3.5%) were less common with soccer than with skiing, but more common than with cycling. The angle (25%) was the second most common site of fracture, whereas ramus fractures (7.1%) in soccer slightly outnumbered those in skiing and cycling. No fractures were diagnosed in the condylar and coronoid regions. PREVALENCEOF ASSOCIATED CRANIOCEREBRAL
OROFACIAL INJUIUES
AND
Orofacial and craniocerebral injuries accompanying mandibular fractures were evaluated using the prevalence rate of associated injuries, which is reported as the number of associatedinjuries per 100 mandibular fractures (Table 1). With mandibular fractures occurring asthe only facial injury in 25% of the mandibu-
Subcond. 54 41 8
Condylar 7 7 0
Coronoid 1 0 0
Fracture
lar fracture sample, the corresponding prevalence rate of associatedinjuries was found to be 122. Regarding the rates of concomitant facial and craniocerebral injuries (61.7), facial lacerations accounted for 39.6 and cerebral concussion and facial fractures for 12.2 and 10, respectively. No skull fractures were diagnosed. Facial fractures associated with mandibular fractures showed a value of 10, with the zygoma the most common site affected (4.9), followed by maxillary fractures (2.4) nasal fractures (1.5), and orbital fractures (1.2). Within the group of associated oral injuries (60.3), tooth fractures (22.7) and mucosal lacerations (17.8) were the most common. Tooth luxation rated 11.7, alveolar process fractures 5.8, and tooth loss 2.1. Associated injuries were encountered with 133.3 per 100 of skiing related mandibular fractures, and an absence of associated injuries was found with 26% of the mandibular fractures. The facial soft tissue (37.1) was the site most frequently injured concomitantly, followed by mucosal lacerations (25.8) and tooth fractures (22.6). Cerebral concussion and facial fractures accounted for 15.1 and 13.4, respectively, whereas tooth luxation (8.6), alveolar process fractures (8.1) and tooth loss (2.7) were less prevalent. With regard to associated facial fractures, there was a rate of 7.5 zygomatic fractures, 3.8 maxillary fractures, 1.6 nasal fractures, and 0.5 orbital fractures per 100 mandibular fractures (Figs X-10). Cycling accidents with concomitant mandibular fractures showed a considerable rate of associatedinjuries (175.6), characterized by significantly higher incidences of associated facial lacerations (73.2) tooth fractures (39), tooth luxation (24.4), and orbital fractures (3.7), whereas zero associated injuries (12% of the mandibular fractures), mucosal lacerations (8.5), alveolar process fractures (4.9), zygomatic fractures (2.4) and maxillary fractures (1.2) had significantly
590
TRENDS
lower rates than in skiing-related injuries. Cerebral concussion (13.4), facial fractures (9.7), nasalfractures (2.4), and tooth loss (2.4) were approximately as frequent as for skiing-related injuries with mandibular fractures (Figs S-10).
Table Rates
IN
1.
SPORT-RELATED
Orofacial
MANDIBULAR
FRACTURES
and Craniocerebral
Sport Slamg
Injury
Groups
cyclmg
soccer
other
Total 197 162 40 327 60.3 49.5 12.2
Oral injuries Facial injuries Craniocerebral injuries Mandibular fractures Oral injury rate* Facial injury rate* Craniocerebral injury rate* Orofaclal and craniocerebral iniurv rate*
126 94 28 186 67.7 50.5 15.1
65 6X 11 82 79.3 82.9 13.4
5 1 28 17.9 3.6
1 31 3.2 -
133.3
175.6
21.4
3.2
* Rates expressed tures. - No injuries.
of injuries
as number
per 100 mandibular
122 frac-
In patients with soccer accidents, there was an associated injury rate of 21.4 and no associatedinjuries in 75% of the total number of soccer-related mandibular fractures. Musocal lacerations (10.7) tooth luxation (7.1), and cerebral concussion (3.6) were the only injuries found to be associatedwith mandibular fractures (Figs S-10). Discussion
C
FIGURE 7. A, Anatomic distribution of mandibular fractures caused by skiing accidents. B, Anatomic distribution of mandibular fractures caused by cycling accidents. C, Anatomic distribution of mandibular fractures caused by soccer accidents.
The age distribution of the patients in the current study corresponded to the results of several other authors, with the peak incidence of mandibular fractures between the agesof 20 and 30 years.3-5These findings most likely reflect the high levels of physical activity in that age-group. The male-to-female ratio in this study contrasts with the findings of other studies that report significantly lower ratios.3-5The reason for this difference may be attributed to the high percentage of females involved in cycling-related accidents. Furthermore, an analysis of the yearly male-to-female ratios showed an increase of 7.5% in the percentage of females involved from 1984 to 1988 to 1989 to 1993. This may be a reflection of a general trend toward an increasing percentage of females sustaining sportrelated injuries. An increase in the yearly distribution of sports-related mandibular fractures from 28.6% in 1984 to 1988 to 34.5% in 1989 to 1993 was noted. The results of this study indicate a considerable change in the cause of thesemandibular fractures. This finding is consistent with the reports of other authors, who have shown that sporting injuries are becoming increasingly common.@ With skiing accidents constituting the main causative factor, the monthly distribution showed January, February, and March to be associatedwith the highest incidence of sports-related mandibular fractures. These
EMSHOFF
591
ET AL
Prevalence
Rate of Injuries
Cerebral Cont. FIGURE 8. Distribution of facial and craniocerebral injuries associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Skull Fracture Facial Lat. Facial Fracture 0
20 Cerebral Cont.
are the months when significant snowfall and vacations provide a greater opportunity for sports activities such as skiing and sledding. The highest incidence of mandibular fractures attributable to soccer, mountaineering, and paragliding was between May and October, corresponding to the warmer weather and high levels of such physical activity during this period. This study showed sporting activities to be the main causative factor of mandibular fractures, 31.5% of the entire sample. This finding contrasts with the reported incidence in the literature ranging from 1.4% to 5.4%. The difference may be attributable to both the geographic location of Innsbruck, with its extensive recreation and sports facilities, and the importance of activity holidays within the tourism industry in this region. An analysis of the yearly distribution of sports-related manibular fractures showed significant changes in the incidence of cycling-related mandibular fractures, with an increase of 19.3% from 1984 to 1988 to 1989 to
Prevalence
40
60
Type of injury / Skull Fracture / Facial Lat.
80 Facial Fracture
1993 and a decreaseof similar magnitude (19.5%) in skiing-related mandibular fractures. With regard to the significant upward trend in cycling-related mandibular fractures, children accounted for a considerable proportion of the total. This finding may suggest an increasing need for preventive programs in relation to cycling for children. Correlations between the causeand the anatomic site of the mandible fracture are discussedin the literature. Olson et al3 and Ellis et al4 reported that patients involved in motor vehicle accidents showed a high incidence of condylar fractures, whereas those who suffered assaultshad a high incidence of angle fractures. Analysis of the anatomic distribution of mandibular fractures showed that in skiing, cycling, and soccerrelated injuries the subcondylar region was the most common site affected, whereas in soccer-related accidents there was a relative high frequency of angle fractures. Thus, these results support the recommendation
Rate of Injuries
Nose Maxilla FIGURE 9. Distribution of facial fractures associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Zygoma Orbita 0
SoccerH Cycling m SkiinglB
2 Nose 0 2,4
I,6
4 Location of Injury Maxilla Zygoma 0 0 12 2,4 398 7,5
6
i
8 Orbita 0 3,7 03
TRENDS IN SPORT-RELATED
592 Prevalence
MANDIBULAR
FRACTURES
Rate of lniuries
Laceration Tooth Frac. FIGURE 10. Distribution of oral injuries associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Tooth Lux. Tooth Loss Alveol. Frac.
SoccerI Cycling &I Skiing&3
Laceration IO,7 895 25,8
/ Tooth Frac. 0 39 22,6
Type of Injury 1 Tooth Lux. j Tooth Loss 0 791 24,4 2,4 8,6 2,7
that skiers and cyclists should wear safety helmets that cover the chin and thereby protect the condylar process.2’9 The results of this study show sports-related mandibular fractures to be associatedwith a considerable prevalence of accompanying orofacial and craniocerebral injuries (122). The value of concomitant facial fractures was 10 per hundred whereas facial lacerations accounted for 39.6 per hundred Olson et al3 found other facial fractures in 25.5% and facial lacerations in 29.8% of patients with mandibular fractures, with motor vehicle accidents as the main causative factor (47.8%). Higher frequencies of associated facial injuries may be attributable to the fact that motor vehicle accidents cause more severe facial trauma than do those related to sports injuries, as investigated in this study. However, the results are not directly comparable because the current study was conducted using the concept of mandibular fracture incidence as the denominator for comparing orofacial and craniocerebral injuries instead of the standard practice of using number of patients. An analysis of the occurrence of associated injuries with respect to cause indicates that cycling-related mandibular fractures result in the highest rates of concomitant orofacial and craniocerebral trauma (175.6), followed by skiing (133.3) and soccer (21.4). An im-
1 Alveol. Frac. 0 49
831
portant finding of this study is the predominance of alveolar process fractures in skiing-related mandibular fractures (8.1) and of tooth injuries in cycling-related incidents (65.8). This would underscorethe importance of preventive measuresto reduce the frequency of dentoalveolar trauma in patients involved in skiing and cycling accidents. References 1. Voss R: The aetiology of jaw fractures in Norwegian patients. J Oral Maxillofac Surg 10:146, 1982 2. Linn EW, Vrijhoef MMA, De Wijn JR, et al: Facial injuries sustained during sport and games. J Craniomaxillofac Surg 14:83, 1986 3. Olson RA, Fonseca RJ, Zeitler DC, et al: Fractures of the mandible: A review of 580 cases. J Oral Maxillofac Surg 40:23, 1982 4. Ellis E, Moos KF, El Attar A: Ten years of mandibular fractures: An analysis of 2137 cases. Oral Surg 59:120, 1985 5. Melmed EP, Koonin AJ: Fractures of the mandible: A review of 909 cases. J Plast Reconstr Surg 56:323, 1975 6. Afzelius LE, Rosen C: Facial fractures: A review of 368 cases. Int J Oral Surg 9:252, 1982 7. Brook IM, Wood N: Aetiology and incidence of facial fractures in adults. Int J Oral Surg 12:293, 1983 8. Hill CM, Crosber RF, Carrol MF, et al: Facial fractures: The results of a prospective four year study. J Oral Maxillofac Surg 12:267, 1984 9. Lindquist C, Sorsa S, Hyrkas T, et al: Maxillofacial fractures sustained in bicycle accidents. Int J Oral Surg 15:12, 1986
Trends in the Incidence and Cause of Sport-Related Mandibular Fractures: A Retrospective Analysis RijDlGER EMSHOFF, MD, DMD,* HARALD SCHONING, MD, DMD,t GABRIEL RijTHLER, MD, DMD,$ AND ERNST WALDHART, MD, DMD§ Purpose: This study assessed changes in the incidence and causes of mandibular fractures occurring in Innsbruck, Austria between 1984 and 1993. Patients and Methods: Records from 712 patients sustaining 982 mandibular fractures were reviewed and analyzed according to age, sex, date of fracture, place of trauma, cause, anatomic site of fracture, and associated orofacial and craniocerebral injuries. Results: Sports were the most common cause of mandibular fractures, accounting for 31.5% of the entire sample, followed by road traffic accidents (27.2%) and falls (20.8%). The yearly distribution of sport-related mandibular fractures showed an increase from 28.6% in 1984 to 1988 to 34.5% in 1989 to 1993. The major causative factor in sports-related mandibular fractures was skiing (55.3%), whereas cycling and soccer accounted for 25.4% and 8.9%, respectively. Significant changes in the occurrence of cycling-related mandibular fractures were observed, with an increase of 19.3% from 1984 to 1988 to 1989 to 1993, whereas skiing-related mandibular fractures showed a decrease of similar magnitude (19.5%). Sex distribution showed a male-to-female ratio of 2.5:1, with the percentage of females involved increasing. In cases of cycling-related accidents, there was a considerable prevalence of associated injuries (133.3 injuries per 100 mandibular fractures), with significantly higher rates of facial lacerations (73.2), tooth fractures (39), tooth luxations (24.4) and orbital fractures (3.7) than in the case of skiing-related injuries, whereas in patients sustaining mandibular fractures caused by soccer, mucosal lacerations, tooth luxations, and cerebral concussions were the only associated injuries found. Conc/usions: The results of this study indicate a considerable change in the cause of mandibular fractures, showing that spotting injuries are becoming increasingly common. The high incidence of associated maxillofacial injuries in patients involved in skiing and cycling accidents may suggest an increasing need for preventive and protective measures.
Changing trends in the cause and number of facial injuries are important for developing recommendations for preventive measures and requirements in oral and maxillofacial surgery training programs. Studies from several countries describe traffic accidents, assaults, and falls as the most frequent causes of maxillofacial fractures. According to the investigations of Voss’ and Linn et al,’ sports-related injuries seem to be increasingly implicated in the causes of maxillofacial injuries. To evaluate trends in the occurrence of sports-related
Received from the Department of Oral and Maxlllofacial Surgery, University of Innsbruck, Austna. * Resident. f Resident. f Associate Professor. 5 Professor and Head. Address correspondence and reprint requests to Dr Emshoff: Hohenstral3e 5, A-6020 Innsbruck. Austria. 0 1997 American
Association
of Oral and Maxillofacial
Surgeons
0278-2391/97/5506-0009$3.00/O
585
586
70
TRENDS IN SPORT-RELATED Number of Patients
_-_-
---
___.- _._.____
MANDIBULAR
FRACTURES
-._ _
60 50 40 FIGURE 1. Age and sex distribution of patients with mandibular fractures.
30 20 10 o-9
IO-19
29-29
30-39
40-49
50-59
60-69
70-79
80-89
Age Group Male OFemale
to sports (31.5%). The patients with sports-related mandibular fractures ranged in age from 4 to 75 years, with 38.4% of the cases occurring between the ages of 10 and 29 years. The highest incidence was found in the 20- to 29-year age-group and the lowest in the 70- to 79-year age-group (Fig 1). Seventy-four percent of all fractures occurred in men and boys, and 26% occurred in women and girls, giving a male-to-female ratio of 2.5: 1. There was an increase in the percentage of females from 24.8% in 1984 to 1988 to 32.3% in 1989 to 1993.
facial trauma, a retrospective analysis of mandibular fractures treated at the Department of Oral and Maxillofacial Surgery, University of Innsbruck, Austria, during the years 1984 to 1993 was undertaken. Materials
and Methods
The records of all patients sustaining mandibular fractures from January 1984 to December 1993 were evaluated for the following data: age, sex, date of fracture, place of trauma, cause, anatomic site of fracture, and associated maxillofacial and non-maxillofacial injuries.
YEARLY AND MONTHLY DISTRIBUTIONOF MANDIBULARFRACTURES
Results
A yearly comparison of the number of patients with sports-related fractures compared with the total number of patients with fractures showed an uneven distribution over the lo-year period (Fig 2). A minimum of
In the lo-year period of this study, there were 712 patients with mandibular fractures, 224 of whom had suffered at least one mandibular fracture attributable
In_
Number of Patients
80 FIGURE 2. Yearly distribution of sports-related mandibular fractures m relation to the total number of patients with mandibular fractures.
60 40 20
1993
1992
1991
1990
1989
1988 Year
Sport-Related
-Total
1987
1986
1985
1984
EMSHOFF
587
ET AL
1988 - 1984
1993 - 1989 65.7%
d
FIGURE 3. Frequency of causes of sports-related mandibular fractures for the years 1984 to 1988 and 1989 to 1993.
FQSkiing
BXycling
BlSoccer
ElParagliding
BlGolf
LB Ice Hockey EYEI Boxing
25% sports-related fractures occurred in 1990, and a maximum of 45% occurred in 1991. There was an increase from 28.6% sports-related fractures in 1984 to 1988 to 34.5% in 1989 to 1993. Although the percentage of mandibular fractures caused by cycling increased from 15.2% in 1984 to 1988 to 34.5% in 1989 to 1993, the percentage of mandibular fractures related to skiing decreased from 65.7% in 1984 to 1988 to 46.2% in 1989 to 1993. The yearly frequency of soccer-related mandibular fractures showed an average percentage of 10.1% in 1989 to 1993 and 7.6% in 1984 to 1988 (Fig 3). The incidence of sports-related mandibular fractures correlated significantly with certain months. December, January, February, and March collectively accounted for the highest percentage (56.6%) of all fractures, and May, October, and November accounted for the lowest (11.5%). Skiing was found to be the most
FBSledding ElMountaineering
common cause during the period November to April (90.9%), whereas injury due to cycling was the prevalent cause of mandibular fractures during the period May to October (73.8%). The distribution of soccerrelated mandibular fractures was uneven from month to month, with an average of 9.9% during the period January to December (Fig 4). CAUSES OF MANDIBULAR
FRACTURES
Of the 712 patients with mandibular fractures occurring in the period 1984 to 1993, sports accidents were the most common cause, accounting for 31.5%. Road traffic accidents constituted 27.2%; falls, 20.8%; and assaults, 12.5%, and the remaining 8% were related to other causes. The major causative factor in sports-related mandib-
Number of Patients 35 30
FIGURE 4. Monthly distribution of sports-related mandibular fractures.
SkiingW Cycling&I SoccerR
Jan 31 1 0
Feb 28 0 0
Mar
Apr
28 0 1
7 3 2
May 1 7 2
Jun 1 11 5
Month
Jul 0 l2,8 2
Aug 2 2
Sept 1 9 3
Ott 3 3 1
1 Nov 5 2 2
Dee 17 1 0
TRENDS IN SPORT-RELATED
588
MANDIBULAR
FRACTURES
Skiing Male El Female
Soccer 100%
60%
Mountaineering
Sledding
25%
30% 75%
70%
100% Golf
Boxing 100%
Paragliding
100%
Ice Hockey 100%
FIGURE 5. Sex distribution of sports-related mandibular fractures according to the respective cause.
ular fractures was skiing, representing 55.3% of the entire sample. The second most common cause was cycling (25.4%), followed by soccer accidents (8.9%). The causes of the remaining fractures were classified as sledding (4.4%), mountaineering (3.6%), paragliding (0.9%), boxing (OS%), golf (0.5%), and ice hockey (OS%). Of the patients involved in sports-related man~bul~ fractures, 71% were men or boys and 29% women or girls. Figure 5 shows the sex distribution with respect to the causative groups. Of the patients sustaining mandibular fractures att~butable to skiing, 70% were men or boys and 30% were woman or girls. A total of 66.9% of these patients were younger than 30 years of age, whereas 41.4% of the injuries occurred in the 20- to 2Pyears age-group. Most patients involved in bicycle accidents were men or boys, accounting for 60%, whereas women or girls accounted for 40% of the injuries. A total of 50.9% of the cases involved were patients younger than 20 years of age, and 14. I % of the accidents occurred in the 0- to 9-year age-group. The patients involved in soccer accidents were solely
young males. Eighty percent of them were younger than age 30 years. Sledding and mountaineering showed a male predominance of 70% and 75%, respectively, whereas only male patients were involved in injuries caused by p~agliding, boxing, golf, and ice hockey. ANATOMIC DISTRIBUTIONOF MANDIBULAR FRACTURES
There were 327 sports-related mandibular fractures in the 224 patients, averaging 1.5 fractures per mandible. Of these, 34.9% involved the subcondylar area, 16.8% the symphysis area (defined as the region between the canines), and 18% the anterior body. Angle fractures accounted for 13.8% and posterior body fractures for 5.2%. Fractures of the ramus, the condyle, and the coronoid occurred in 5.2%, 4.9%, and 0.3% of the total, respectively. Figure 6 shows the variations in the number of m~dibul~ fractures according to the anatomic site and the causes-skiing, cycling, and soccer.
589
EMSHOFF ET AL Number of Mandibular
Fractures
60 50 40 30
FIGURE 6. Anatomic distribution of mandibular fractures caused by skiing, cycling, and soccer accidents.
20
10 0 Skiing= CyclingE Soccer=
Symphysis 35 11 5
Ant. Body 39 11 5
Post. Body 12 4 1
Angie 29 5 7
Ramus 9 3 2
Location of Mandibular
The subcondylar area was the most common site of fractures associatedwith skiing injuries (32.8%) (Fig 7A), followed by fractures of the anterior body (21%) and the symphyseal area (18.8%). Fractures of the angle and the posterior body showed an incidence of 15.6% and 6.5%, respectively, whereas ramus (4.8%) and condylar fractures (3.X%) occurred lessfrequently. An analysis of cycling accidents (Fig 7B) showed significantly fewer incidents of anterior body (13.4%) and angle fractures (6.1%), whereas subcondylar (50%) and condylar fractures (8.5%) were more frequent than in skiing injuries. Symphysis fractures were diagnosed in 13.4% of the sample, whereas fractures of the posterior body and the ramus constituted 4.9% and 3.7%, respectively. There were no fractures in the coronoid region. The most common site of mandibular fractures resulting from soccer injuries (Fig 7C) was the subcondylar area (28.6%), with a frequency similar to that of skiing injuries. Fractures of the symphysis area (17.9%), the anterior body (17.9%), and the posterior body (3.5%) were less common with soccer than with skiing, but more common than with cycling. The angle (25%) was the second most common site of fracture, whereas ramus fractures (7.1%) in soccer slightly outnumbered those in skiing and cycling. No fractures were diagnosed in the condylar and coronoid regions. PREVALENCEOF ASSOCIATED CRANIOCEREBRAL
OROFACIAL INJUIUES
AND
Orofacial and craniocerebral injuries accompanying mandibular fractures were evaluated using the prevalence rate of associated injuries, which is reported as the number of associatedinjuries per 100 mandibular fractures (Table 1). With mandibular fractures occurring asthe only facial injury in 25% of the mandibu-
Subcond. 54 41 8
Condylar 7 7 0
Coronoid 1 0 0
Fracture
lar fracture sample, the corresponding prevalence rate of associatedinjuries was found to be 122. Regarding the rates of concomitant facial and craniocerebral injuries (61.7), facial lacerations accounted for 39.6 and cerebral concussion and facial fractures for 12.2 and 10, respectively. No skull fractures were diagnosed. Facial fractures associated with mandibular fractures showed a value of 10, with the zygoma the most common site affected (4.9), followed by maxillary fractures (2.4) nasal fractures (1.5), and orbital fractures (1.2). Within the group of associated oral injuries (60.3), tooth fractures (22.7) and mucosal lacerations (17.8) were the most common. Tooth luxation rated 11.7, alveolar process fractures 5.8, and tooth loss 2.1. Associated injuries were encountered with 133.3 per 100 of skiing related mandibular fractures, and an absence of associated injuries was found with 26% of the mandibular fractures. The facial soft tissue (37.1) was the site most frequently injured concomitantly, followed by mucosal lacerations (25.8) and tooth fractures (22.6). Cerebral concussion and facial fractures accounted for 15.1 and 13.4, respectively, whereas tooth luxation (8.6), alveolar process fractures (8.1) and tooth loss (2.7) were less prevalent. With regard to associated facial fractures, there was a rate of 7.5 zygomatic fractures, 3.8 maxillary fractures, 1.6 nasal fractures, and 0.5 orbital fractures per 100 mandibular fractures (Figs X-10). Cycling accidents with concomitant mandibular fractures showed a considerable rate of associatedinjuries (175.6), characterized by significantly higher incidences of associated facial lacerations (73.2) tooth fractures (39), tooth luxation (24.4), and orbital fractures (3.7), whereas zero associated injuries (12% of the mandibular fractures), mucosal lacerations (8.5), alveolar process fractures (4.9), zygomatic fractures (2.4) and maxillary fractures (1.2) had significantly
590
TRENDS
lower rates than in skiing-related injuries. Cerebral concussion (13.4), facial fractures (9.7), nasalfractures (2.4), and tooth loss (2.4) were approximately as frequent as for skiing-related injuries with mandibular fractures (Figs S-10).
Table Rates
IN
1.
SPORT-RELATED
Orofacial
MANDIBULAR
FRACTURES
and Craniocerebral
Sport Slamg
Injury
Groups
cyclmg
soccer
other
Total 197 162 40 327 60.3 49.5 12.2
Oral injuries Facial injuries Craniocerebral injuries Mandibular fractures Oral injury rate* Facial injury rate* Craniocerebral injury rate* Orofaclal and craniocerebral iniurv rate*
126 94 28 186 67.7 50.5 15.1
65 6X 11 82 79.3 82.9 13.4
5 1 28 17.9 3.6
1 31 3.2 -
133.3
175.6
21.4
3.2
* Rates expressed tures. - No injuries.
of injuries
as number
per 100 mandibular
122 frac-
In patients with soccer accidents, there was an associated injury rate of 21.4 and no associatedinjuries in 75% of the total number of soccer-related mandibular fractures. Musocal lacerations (10.7) tooth luxation (7.1), and cerebral concussion (3.6) were the only injuries found to be associatedwith mandibular fractures (Figs S-10). Discussion
C
FIGURE 7. A, Anatomic distribution of mandibular fractures caused by skiing accidents. B, Anatomic distribution of mandibular fractures caused by cycling accidents. C, Anatomic distribution of mandibular fractures caused by soccer accidents.
The age distribution of the patients in the current study corresponded to the results of several other authors, with the peak incidence of mandibular fractures between the agesof 20 and 30 years.3-5These findings most likely reflect the high levels of physical activity in that age-group. The male-to-female ratio in this study contrasts with the findings of other studies that report significantly lower ratios.3-5The reason for this difference may be attributed to the high percentage of females involved in cycling-related accidents. Furthermore, an analysis of the yearly male-to-female ratios showed an increase of 7.5% in the percentage of females involved from 1984 to 1988 to 1989 to 1993. This may be a reflection of a general trend toward an increasing percentage of females sustaining sportrelated injuries. An increase in the yearly distribution of sports-related mandibular fractures from 28.6% in 1984 to 1988 to 34.5% in 1989 to 1993 was noted. The results of this study indicate a considerable change in the cause of thesemandibular fractures. This finding is consistent with the reports of other authors, who have shown that sporting injuries are becoming increasingly common.@ With skiing accidents constituting the main causative factor, the monthly distribution showed January, February, and March to be associatedwith the highest incidence of sports-related mandibular fractures. These
EMSHOFF
591
ET AL
Prevalence
Rate of Injuries
Cerebral Cont. FIGURE 8. Distribution of facial and craniocerebral injuries associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Skull Fracture Facial Lat. Facial Fracture 0
20 Cerebral Cont.
are the months when significant snowfall and vacations provide a greater opportunity for sports activities such as skiing and sledding. The highest incidence of mandibular fractures attributable to soccer, mountaineering, and paragliding was between May and October, corresponding to the warmer weather and high levels of such physical activity during this period. This study showed sporting activities to be the main causative factor of mandibular fractures, 31.5% of the entire sample. This finding contrasts with the reported incidence in the literature ranging from 1.4% to 5.4%. The difference may be attributable to both the geographic location of Innsbruck, with its extensive recreation and sports facilities, and the importance of activity holidays within the tourism industry in this region. An analysis of the yearly distribution of sports-related manibular fractures showed significant changes in the incidence of cycling-related mandibular fractures, with an increase of 19.3% from 1984 to 1988 to 1989 to
Prevalence
40
60
Type of injury / Skull Fracture / Facial Lat.
80 Facial Fracture
1993 and a decreaseof similar magnitude (19.5%) in skiing-related mandibular fractures. With regard to the significant upward trend in cycling-related mandibular fractures, children accounted for a considerable proportion of the total. This finding may suggest an increasing need for preventive programs in relation to cycling for children. Correlations between the causeand the anatomic site of the mandible fracture are discussedin the literature. Olson et al3 and Ellis et al4 reported that patients involved in motor vehicle accidents showed a high incidence of condylar fractures, whereas those who suffered assaultshad a high incidence of angle fractures. Analysis of the anatomic distribution of mandibular fractures showed that in skiing, cycling, and soccerrelated injuries the subcondylar region was the most common site affected, whereas in soccer-related accidents there was a relative high frequency of angle fractures. Thus, these results support the recommendation
Rate of Injuries
Nose Maxilla FIGURE 9. Distribution of facial fractures associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Zygoma Orbita 0
SoccerH Cycling m SkiinglB
2 Nose 0 2,4
I,6
4 Location of Injury Maxilla Zygoma 0 0 12 2,4 398 7,5
6
i
8 Orbita 0 3,7 03
TRENDS IN SPORT-RELATED
592 Prevalence
MANDIBULAR
FRACTURES
Rate of lniuries
Laceration Tooth Frac. FIGURE 10. Distribution of oral injuries associated with mandibular fractures caused by skiing, cycling, and soccer accidents. Prevalence rate described as number of injuries per 100 mandibular fractures.
Tooth Lux. Tooth Loss Alveol. Frac.
SoccerI Cycling &I Skiing&3
Laceration IO,7 895 25,8
/ Tooth Frac. 0 39 22,6
Type of Injury 1 Tooth Lux. j Tooth Loss 0 791 24,4 2,4 8,6 2,7
that skiers and cyclists should wear safety helmets that cover the chin and thereby protect the condylar process.2’9 The results of this study show sports-related mandibular fractures to be associatedwith a considerable prevalence of accompanying orofacial and craniocerebral injuries (122). The value of concomitant facial fractures was 10 per hundred whereas facial lacerations accounted for 39.6 per hundred Olson et al3 found other facial fractures in 25.5% and facial lacerations in 29.8% of patients with mandibular fractures, with motor vehicle accidents as the main causative factor (47.8%). Higher frequencies of associated facial injuries may be attributable to the fact that motor vehicle accidents cause more severe facial trauma than do those related to sports injuries, as investigated in this study. However, the results are not directly comparable because the current study was conducted using the concept of mandibular fracture incidence as the denominator for comparing orofacial and craniocerebral injuries instead of the standard practice of using number of patients. An analysis of the occurrence of associated injuries with respect to cause indicates that cycling-related mandibular fractures result in the highest rates of concomitant orofacial and craniocerebral trauma (175.6), followed by skiing (133.3) and soccer (21.4). An im-
1 Alveol. Frac. 0 49
831
portant finding of this study is the predominance of alveolar process fractures in skiing-related mandibular fractures (8.1) and of tooth injuries in cycling-related incidents (65.8). This would underscorethe importance of preventive measuresto reduce the frequency of dentoalveolar trauma in patients involved in skiing and cycling accidents. References 1. Voss R: The aetiology of jaw fractures in Norwegian patients. J Oral Maxillofac Surg 10:146, 1982 2. Linn EW, Vrijhoef MMA, De Wijn JR, et al: Facial injuries sustained during sport and games. J Craniomaxillofac Surg 14:83, 1986 3. Olson RA, Fonseca RJ, Zeitler DC, et al: Fractures of the mandible: A review of 580 cases. J Oral Maxillofac Surg 40:23, 1982 4. Ellis E, Moos KF, El Attar A: Ten years of mandibular fractures: An analysis of 2137 cases. Oral Surg 59:120, 1985 5. Melmed EP, Koonin AJ: Fractures of the mandible: A review of 909 cases. J Plast Reconstr Surg 56:323, 1975 6. Afzelius LE, Rosen C: Facial fractures: A review of 368 cases. Int J Oral Surg 9:252, 1982 7. Brook IM, Wood N: Aetiology and incidence of facial fractures in adults. Int J Oral Surg 12:293, 1983 8. Hill CM, Crosber RF, Carrol MF, et al: Facial fractures: The results of a prospective four year study. J Oral Maxillofac Surg 12:267, 1984 9. Lindquist C, Sorsa S, Hyrkas T, et al: Maxillofacial fractures sustained in bicycle accidents. Int J Oral Surg 15:12, 1986