SCIENTIFIC ARTICLE

Australian Dental Journal 2002;47:(2):131-137

Mandibular fracture patterns in Tasmania, Australia

P Dongas*, GM Hall*

Abstract
Background: No previous studies on mandibular
fracture patterns in Tasmania, and very few
elsewhere in Australia, have undertaken to discover
which identified age, gender, aetiology, anatomical
location of the fracture, period of injury, whether
alcohol consumption was associated with the injury,
and treatment of mandibular fractures.
Method: A retrospective study was undertaken of
251 patients with fractured mandibles presenting to
the Royal Hobart Hospital, Tasmania from 19931999. Data were obtained from the Oral and
Maxillofacial Surgery unit fracture record books
cross-checked with patients, impatient/outpatient
hospital records.
Results: The male to female ratio was 4.5:1, with
mandibular fractures most common in the male age
group of 21-30 years. Assaults (55 per cent of all
patients) were the major cause of fractures. Males
accounted for 85.5 per cent of assaults, with
punching being the most common method, followed
by motor vehicle accidents (MVA), 18.3 per cent and
sport, 16.7 per cent. In sport, Australian Rules
Football was the most common cause, accounting
for 45.2 per cent of sporting injuries. The site most
frequently fractured was the angle of the mandible.
Alcohol abuse was seen in 41.4 per cent of the
patients with 84.6 per cent being male. Open
reduction and internal fixation with miniplate
osteosynthesis, was the preferred treatment
modality. The results are compared with other series.
Conclusions: Mandibular fractures are common in
Tasmania, with the highest rates involved in assaults
and sport (especially Australian Rules Football) and
a low rate in MVA. These fractures commonly
occurred in young males in which assaults, alcohol
and social issues were associated. Therefore,
preventive measures and strong public awareness
addressing this group may be of benefit in reducing
the rate of assaults and sporting injuries to the
mandible.
Key words: Mandibular fracture, aetiology, alcohol, facial
trauma.
(Accepted for publication 20 December 2000.)

*Oral and Maxillofacial Surgery Unit, Royal Hobart Hospital,

The University of Tasmania.
Australian Dental Journal 2002;47:2.

INTRODUCTION
The facial area is one of the most frequently injured
areas of the body,1-4 and the mandible is one of the most
common maxillofacial bones fractured,1,5,6 due to its
prominent position on the face.
Studies around the world have shown that assaults
are the predominant cause of maxillofacial fractures in
developed countries, while motor vehicle accidents
(MVA) are the most common cause in developing
countries.2,7-13
Aetiology varies from country to country and they
can usually be attributed to cultural, social,
environmental and economical factors. The relationship
between alcohol consumption and maxillofacial
injuries is well known.1,6,10,14,15
Treatment of mandibular fractures has changed over
the last 20 years in Western societies. There has been a
decrease in the use of wire osteosynthesis and intermaxillary fixation and an increase in preference for
open reduction and internal fixation with miniplates.15,16
This has helped reduce malocclusion, non-union,
improved mouth opening, speech and oral hygiene,
decreased weight loss and increased the ability for
patients to return to work earlier.15,17
Limited information is available regarding
mandibular fracture patterns in Australia, and no
previous study has been undertaken in Tasmania,
Australia. The aim of the study was to examine the
incidence, aetiology, age, gender, anatomical distribution,
consumption of alcohol prior to trauma, and treatment
of mandibular fractures presenting to the Royal Hobart
Hospital, Tasmania, Australia, and to compare these
with other studies. The results may aid in identifying
aetiological factors and in planning strategies for
prevention.
M AT E R I A L S A N D M E T H O D S
A retrospective study of all mandibular fractures seen
at the Royal Hobart Hospital from January 1993 to
August 1999 inclusive, was undertaken. Data for each
patient were obtained from the Oral and Maxillofacial
Surgery Unit fracture record books. The data were
cross checked by reviewing each patients hospital
inpatient/outpatient records. The data obtained
included: age, gender, yearly/monthly fracture
131

Table 1. Age and gender distribution

25

25
20
15

23

21

19

20

19
16

14 15
11

Dec

Jan

distribution, aetiology, anatomical fracture site,

alcohol/drug association and treatment.

Nov

10
5
0
Oct

251 (100)

30

Sep

46 (18.3)

32

35

Jul

205 (81.7)

(3.2)
(29.5)
(34.7)
(18.3)
(7.2)
(3.9)
(3.2)

Aug

Total

8
74
87
46
18
10
8

Jun

2
11
15
7
4
2
5

May

6
63
72
39
14
8
3

Apr

0-10
11-20
21-30
31-40
41-50
51-60
61

40 36
Total (%)

Mar

Female

Feb

Male

Number of patients

Age (yrs)

Month

R E S U LT S
During the seven-year period (1993-1999) a total of
251 patients had sustained 385 mandibular fractures.
The average number of patients (with mandibular
fractures) that presented annually to the department
was 35.9, and the annual average of mandibular fractures was 55.
Age and gender distribution
Patients with mandibular fractures ranged in age
from a 2-year-old male involved in a MVA, to an 87year-old female who was a victim of an assault. There
were 205 males and 46 females accounting for the total
of 251 patients, with a male to female ratio of 4.5:1.
The majority of mandibular fractures for both males
and females occurred in the age group of 21-30 years
(34.7 per cent 87 patients), and the most frequent age
was 21 years (Table 1).
Yearly and monthly distribution
The total number of mandibular fractures per year
was constant, with the highest incidence in 1996
(Fig 1). The monthly distribution showed January to
have the highest incidence, followed closely by May.
The lowest incidence was November (Fig 2).
Aetiology of mandibular fractures
The most common cause of mandibular fractures
was assault (55 per cent), followed by MVA (18.3 per
46

50

Number of patients

40
40

35
31

30

25

Table 2. Aetiology of mandibular fractures

20

Aetiology

10
0
1993 1994 1995 1996 1997 1998 1999
Year
Fig 1. Yearly distribution.

132

cent) and sport (16.7 per cent): see Table 2. Of the

patients involved in alleged assaults, 85.5 per cent were
male and 14.5 per cent were female. There were 68.8
per cent males and 11.6 per cent females involved in
alleged punch(es). The assault breakdown is shown in
Table 3. The alleged assaults occurred in bar fights (the
most common place), home or public places, domestic
disputes, parties, and home invasion.
Of the patients involved in MVA, 73.9 per cent were
male and 26.1 per cent female. A total of 50 per cent of
the MVA victims, were involved in an automobile
accident (Table 3). Of the patients involved in sport,
83.3 per cent were male and 16.7 per cent were female.
Australian Rules Football was the predominant
sporting activity, in which 45.2 per cent males and no
females sustained fractured mandibles. (The entire
sport breakdown is shown in Table 3.) Other causes of
mandibular fractures are listed in Table 2.
In 25 (10 per cent) of the total patients (251), the
mandibular fractures were associated with mid-facial
fractures, and 226 patients (90 per cent) involved only
the mandible. Of the mandibular fractures also
involving the mid-facial area, MVA had the highest
incidence of 52 per cent, 44 per cent were caused by
assaults and 4 per cent by a fall. No associated
mid-facial fractures occurred in the other categories of
aetiology.
Anatomical location of mandibular fractures
In 251 patients, the total number of mandibular
fractures was 385, with an average of 1.53 fractures per
mandible. The angle was the most commonly involved

39

35

Fig 2. Monthly distribution.

Assault
MVA
Sport
Fall
Fit
Industrial
Gunshot
Oral surgery
Total

No. of fractures (%)

138
46
42
13
7
3
1
1
251

(55.0)
(18.3)
(16.7)
(5.2)
(2.8)
(1.2)
(0.4)
(0.4)
(100)

Australian Dental Journal 2002;47:2.

Table 3. Male/Female in aetiological categories

Aetiology

Male

Total (%)

95 (68.8)
15 (10.9)
6
2

16 (11.6)
1 (0.7)
0
3

111 (80.4)
16 (11.6)
6
5

118 (85.5)

20 (14.5)

138 (100)

Coronoid
1.5%

Assault
punch
kick
punch/kick
other
Total

0.8%

Condyle

Female

MVA
automobile
bicycle
motorcycle
pedestrian

14 (30.4)
10 (21.7)
9 (19.6)
1

9 (19.6)
2 (4.3)
0
1

23 (50.0)
12 (26.0)
9 (19.6)
2

Total

34 (73.9)

12 (26.1)

46 (100)

Sport
football
cricket
horse riding
soccer
golf
hockey
bungee jumping
roller blading
netball

19
5
2
3
2
2
1
0
1

Total

35 (83.3)

7 (16.7)

42 (100)

8 (61.5)
6 (85.7)
3
1
0

5 (38.5)
1 (14.3)
0
0
1

13 (100)
7 (100)
3
1
1

Fall
Fit
Industrial
Gun shot
Oral surgery

Subcondyle

23.3%

1.8%

Alveolus 2.1%

Ramus

32.0%

Angle
17.7%

(45.2)
(11.9)
(4.8)
(7.1)

0
2 (4.8)
2 (4.8)
0
1
1
0
1
0

19
7
4
3
3
3
1
1
1

(45.2)
(16.7)
(9.6)
(7.1)

area with 32 per cent of the total fractures. This was

followed by the subcondyle region 23.3 per cent, body
17.7 per cent and the parasymphysis 15.6 per cent. The
remaining fractures each accounted for less than 4 per
cent of the total fractures (Fig 3).
There was no significant difference between the right
side (48.8 per cent) and the left side (51.2 per cent) of
the mandible. The mandible had a single fracture in 53
per cent of the patients, 40.6 per cent had two
fractures, 4.8 per cent three fractures, and 0.8 per cent
had greater than three fractures.
Mandibular fracture pattern combinations
Table 4 shows that of the 138 patients assaulted, the
most common single fracture occurred in the angle of
the mandible in 47 patients (34 per cent). With regards
to MVA (46 patients), a single fracture in the body of
the mandible was the most frequently affected site

15.6%

Body

Symphysis 3.6%
Parasymphysis

Fig 3. Anatomical location of mandibular fractures.

occurring in six patients (13 per cent). Sport related

injuries (42 patients) also resulted in the angle of the
mandible to fracture in 12 patients (28.6 per cent). Falls
and fits (20 patients) most often caused the subcondyle
region to fracture in seven patients (35 per cent).
There were 31 different mandibular fracture
combinations involving more than one fracture. The
most common pattern combinations were angle/
parasymphysis (8 per cent), followed by body/angle
(7.2 per cent), subcondyle/parasymphysis (6.4 per cent)
and subcondyle/body (4 per cent). Of the patients
assaulted, the body/angle (10.1 per cent) was the
predominant combination, followed by the angle/
parasymphysis (8.7 per cent) and the subcondyle/
parasymphysis (7.2 per cent).
Of the patients involved in sport the angle/
parasymphysis (11.9 per cent) was the most common
combination. Sports usually resulted in single fractures
of the mandible, whilst MVA patients were dispersed
over all the different combinations and single fractures.
Alcohol consumption
A total of 104 patients with mandibular fractures
(41.4 per cent) were documented as being under the
influence of alcohol on presentation to the Royal
Hobart Hospital as shown in Table 5. Alcohol
consumption was more commonly associated with
males sustaining more mandibular fractures than
females (84.6 per cent were male and 15.4 per cent
female).
Of all the patients that were under the influence of
alcohol, 79.8 per cent were assault victims in which the

Table 4. Mandibular fracture pattern combinations and aetiology

Assault
Single fracture
subcondyle
angle
body
parasymphysis
Combination fracture
body/angle
angle/parasymphysis
subcondyle/body
subcondyle/parasymphysis
Other
Total
Australian Dental Journal 2002;47:2.

13
47 (34.0)
9
4
14 (10.1)
12 (8.7)
7
10 (7.2)
22
138

MVA
1
3
6 (13.0)
4
2
2
2
3
23
46

Sport
7
12 (28.6)
4
2
2
5 (11.9)
1
2
7
42

Other
8
3
1

Total (%)
29 (11.6)
65 (25.9)
20
10

1
12

18
20
10
16
64

25

251

(7.2)
(8.0)
(4.0)
(6.4)

133

Table 5. Involvement of alcohol by sex

Table 6. Age, alcohol and aetiology

Male

Female

Total (%)

Alcohol
No alcohol

88 (84.6)
117

16 (15.4)
30

104 (41.4)
147

Total

205

46

251

most common age group was 21-30 years (37.3 per

cent). Those that were involved in a MVA (11.5 per
cent), were aged between 31-40 years (33.3 per cent).
Overall the most common age group in which alcohol
consumption was involved resulting in a fractured
mandible was 21-30 years of age (Table 6).
It is important to note that these figures did not take
into account alcohol consumption by assailants and
non-patient motor vehicle drivers/passengers, and only
took into account alcohol use by persons sustaining a
fractured mandible.
Drug use
The study showed that 4.4 per cent of patients with
mandibular fractures involved illicit drug use. This figure
is undoubtedly underestimated as the hospital records
usually do not disclose these details, as patients are often
reluctant to openly reveal such information and
clinicians rarely investigate drug use in every patient.
Treatment of mandibular fractures
The majority of patients with mandibular fractures
(251) were treated by open reduction and internal fixation (ORIF) with miniplates (41.4 per cent). There were
25.9 per cent whom also had ORIF, followed by postoperative intermaxillary fixation (IMF). These patients
had multiple fractures and in most cases it involved the
subcondyle region. Conservative treatment (19.1 per
cent) usually involved a soft diet, analgesia,
diazepam, antibiotics, and the patient was regularly
observed over a six week period.
Closed reduction was the treatment of least choice in
13.6 per cent of the patients, this involved a non
surgical approach of IMF, using eyelet wires or arch
bars and wire or elastics for four to six weeks.
DISCUSSION
The Oral and Maxillofacial Unit of the Royal Hobart
Hospital serves a population of 470,45718 treating all
the mandibular fractures presenting or referred to the
hospital.
Age and gender distribution
In this study, males accounted for 81.7 per cent of all
patients with mandibular fractures, similar to that
reported by Edwards et al. (80 per cent),1 Fridrich et al.
(78 per cent)19 and by Asadi et al. (79 per cent).20 The
male to female ratio of 4.5:1, is consistent with studies
by Allan and Daly5 in Newcastle, Australia and
Edwards et al.1 in Adelaide, Australia. This is slightly
more than the majority of mandibular fracture studies
134

Age(yrs)

Assault
+alcohol

MVA
+alcohol

0-10
11-20
21-30
31-40
41-50
51-60
61+

21 (25.3)
31 (37.3)
21 (25.3)
6
4

2 (16.7)
3 (25.0)
4 (33.3)
1

Total

83 (79.8)

12 (11.5)

Other
+alcohol
2
2
3
1
1
9 (8.7)

Total (%)
25 (24.0)
36 (34.6)
25 (24.0)
10
5
3
104 (100)

around the world, which had a male to female ratio of

approximately 3:1.3,6,19, 21-23
The highest incidence of mandibular fractures
occurred in patients who were 21-30 years of age in
both males and females, with males making up the
majority in this group. This is consistent with findings
of previously published work.3,23
It is well documented that males are more likely to be
involved in violent conduct, participate in contact
sport, and drive recklessly, making them more
susceptible to trauma.3,10,11,24 Therefore, it is not
surprising that males outnumber females in this study.
Yearly and monthly distribution
The total number of mandibular fractures was
moderately constant from year to year, with approximately 35 patients per year, with the exception of 1996,
which had 46 and 1999 with 25 (the study finished at
the end of August).
More fractures occurred in January than any other
month these mainly occurred in early January, when
the New Years eve/day celebrations take place. January
in Australia is also the middle of summer, when
outdoor activities and festivities are attended by large
crowds. Mandibular fractures also prevailed in the
month of May, which coincides with the
commencement of winter contact sports, especially
Australian Rules Football.
Aetiology of mandibular fractures
This study found assaults (55 per cent) to be the
predominant cause of mandibular fractures, followed
by MVA (18.3 per cent), sport (16.7 per cent) and falls
(5.2 per cent). These findings were similar to those
found by Edwards et al.,1 Adi et al.21 and Ellis et al.22
The assault rates reported by Rix et al. (72.5 per
cent) in Sydney, Australia15 and Asadi et al. (74 per
cent) in Manchester, United Kingdom,20 are two of the
highest reported. Both stated that the effects of social
behaviour and alcohol, complicated by everyday
stresses of residing in large city areas are associated
with the increase in interpersonal violence.
An earlier study by Larsen et al.23 in Denmark
showed that MVA (57 per cent) were the most common
cause of mandibular fractures, and that assaults
accounted for 16 per cent. Reports from Sweden, in
Australian Dental Journal 2002;47:2.

1987 by Erikson et al.9 demonstrated that in the periods

1952-1962 and 1975-1985 assaults increased from
26 to 44 per cent, and MVA decreased from 41 to
22 per cent respectively (the mandible was involved in
approximately 83 per cent of jaw fractures). They
accounted for the increase in assaults by stating that
there was an increase in violence, and that the
compulsory use of seat belts explained the decrease in
MVA trauma.9 Therefore, in earlier studies MVA
seemed to be the most common cause of mandibular
fractures. However, recent reports show that assaults
are predominating, as indicated by this study.
Our study also revealed that in assaults, mandibular
fractures occurred in 85.5 per cent males and 14.5 per
cent females. In both males and females punching was
identified as the predominant cause of mandibular
fractures as reported.25
In MVA trauma, 73.9 per cent were male and 26.1
per cent female. As reported in other studies the
majority of MVA involved an automobile in both males
(30.4 per cent) and females (19.6 per cent) cases.2,19 It
was interesting to note that bicycle trauma (26 per cent)
was the second most common cause of MVA resulting
in mandibular fractures, with males sustaining injuries
more frequently than females, at 21.7 per cent. Bicycle
riding is not a common mode of transport in Tasmania.
However, bicycle riding proved to be more common in
causing mandibular fractures than motorcycle accidents.
Perhaps bicycle helmets (which are currently worn in
Tasmania) would benefit from some form of facial
coverage similar to that of a motorcycle helmet.
The percentage of fractures sustained during sports
was 16.7 per cent, this was in agreement with that
reported by Edwards et al. (13 per cent)1 and Allan and
Daly (19 per cent).5 In Tasmania, Australian Rules
Football was strongly associated with mandibular
fractures accounting for 45.2 per cent of all sports and
the entire population was male. Australian Rules
Football has a high participation rate in Tasmania, and
it is also a contact sport in which the male population
predominantly play. The Newcastle study by Allan and
Daly, reported that Rugby was the most popular sport
contributing to mandibular fractures.5 This reflects the
popularity of Rugby in the state of New South Wales,
Australia. Lim et al.,26 from Adelaide reported that
Australian Rules Football was accountable for 52.6 per
cent of the facial fractures.
Only 10 per cent of patients with mandibular
fractures had an associated mid-facial fracture. The
majority, 90 per cent had only mandibular fractures.
MVA were the predominant cause of mandibular
fractures associated with a mid-facial fracture, as seen
in other studies.21,23
Anatomical location
The most common site for mandibular fractures in
the Tasmanian community was the angle of the
mandible, which is consistent with other studies,1,2,19,20,23
followed by the condyle region, then the body of the
Australian Dental Journal 2002;47:2.

mandible. These findings are consistent with the study

by Hammond et al., in Otago, New Zealand.2
However, these results are in contrast with studies in
Nigeria by Oji, in Enugu,11 and Abiose in Ibadan,7
where the mandibular body was identified as the most
common fracture site. In all these studies MVA were
reported to be the leading contributing factors to facial
fractures. Fractures of the body of the mandible were
also common in Scotland where assaults are reported as
the major cause.21,22 These observations show that in
developed countries the angle or body is the most
common place for the mandible to fracture in alleged
assaults, and in developing countries the body is the
predominant position resulting from MVA.
In Tasmania, the angle of the mandible sustained
fractures more frequently from injuries involving
assaults and sport activities. This is not surprising as
this site is commonly weakened by the unerupted
wisdom teeth.2
The most common mandibular fracture combinations
in this study were angle/parasymphysis followed closely
by angle/body. These often occurred as a result of
assaults, with the mandible presumably fracturing in
areas deficient in strength. This is in contrast to the
study by Abiose, in which the body bilaterally was
reported as the most frequent mandibular fracture
combination.7 However, MVA presented to be the most
common cause in that study, not assaults.
Alcohol consumption
Alcohol consumption is a well known contributing
factor to mandibular fractures derived from
assaults.1,6,14,15 This study showed that 41.4 per cent of
patients with mandibular fractures were under the
influence of alcohol when initially assessed at the Royal
Hobart Hospital. Similar figures were shown by
Oikarinen et al. in Oula, Finland, with 44 per cent of
the patients with mandibular fractures under the
influence of alcohol at their first visit to the emergency
unit,14 and Renton and Wiesenfeld in Melbourne,
Australia with 40 per cent of patients having consumed
alcohol.16 A higher figure was reported by Rix et al. in
Sydney, Australia, with alcohol implicated in 58 per
cent of the patients with mandibular fractures.15 They
had reported one of the highest assault rates of 72.5 per
cent (previously reported).
Limitations exist in both retrospective and prospective
studies of alcohol consumption. With retrospective
studies it is difficult to retrieve from case notes the
exact figure. Different clinicians record alcohol
intoxication in different areas of the patient records (as
in the present study), and some may not record it at all.
Thus, the Tasmanian alcohol consumption figure may
be underestimated.
In prospective studies, actual figures may be underestimated also, as identifying alcohol consumption in
assailants and non-patients, not suffering from a
fractured mandible would be difficult, as they do not
always present with the victim. Finally, there is usually
135

a delay in seeking management of the fractured

mandible if the trauma took place under the influence
of alcohol.6
In both retrospective and prospective studies alcohol
breath and blood testing each patient presenting with a
fractured mandible would be difficult but possible with
ethics and council approval for patient protection. In
this study only one patient was alcohol blood and
breath tested (by a police officer) as he was a MVA
victim.
It is interesting to note that Oikarinen et al.,6
commented on a study in the United Kingdom and
France, undertaken by Timoney et al.,27 which reported
that alcohol was more likely to be a contributing factor
in assaults in the United Kingdom than France, even
though France had a higher alcohol consumption rate
per capita than the United Kingdom. Oikarinen et al.
concluded that alcohol consumption and facial trauma
are related to other issues such as social problems and
age of the patient. Telfer et al. claimed a relationship
between facial bone fractures in assaults with alcohol
and unemployment.12
Our study showed that assaults resulting in
mandibular fractures occurred in cases where alcohol
consumption was at its highest (79.8 per cent), and
predominantly amongst young males (21-30yrs).
Tasmania has the highest male unemployment rate
(10.4 per cent) in the nation, compared to the
Australian rate of 7.5 per cent.18 The unemployment
rate in this sample of mandibular fractures could not be
verified, as the medical records were incomplete.
However, the relationship between assault, alcohol
consumption, unemployment and young males,
complicated by complex social issues, undoubtedly
exists and it is not only a direct relationship between
alcohol and assaults.
Treatment of mandibular fractures
In recent years there has been a trend towards ORIF
as the choice of treatment of mandibular fractures.1,2,13,15
Tasmania was no different, with ORIF being the
treatment of choice, in this study.
CONCLUSION
In Tasmania, Australia, fractures of the mandible are
common. There is a low rate of mandibular fractures
associated with MVA, probably due to public awareness of strict traffic laws, for example; compulsory
wearing of seatbelts, random alcohol breath testing and
speed limits. Unfortunately, there was a higher than
expected rate amongst bicycle riders, a helmet with
facial coverage similar to that of a motor cycle helmet
would perhaps be beneficial.
A high rate of mandibular fractures were sustained
by patients involved in assaults and sport (especially
Australian Rules Football). These fractures were
common amongst young males with whom assaults,
alcohol and social issues seemed to be associated.
136

Therefore, it is suggestive that preventive measures

addressing this group with regards to the association of
interpersonal violence and alcohol abuse with
mandibular fractures, may be of benefit. However,
social problems may be difficult to address as they
involve complex issues for example, family background,
and personality types.
In regards to Australian Rules Football the
compulsory wearing of head gear, mouthguards and
possibly looking at rule and regulation changes could be
useful. Both aetiologies would benefit from strong public
awareness if there is to be a reduction in the increasing
rate of assaults and sporting injuries to the mandible.
AC K N OW L E D G M E N T S
The authors would like to thank the staff of the
medical records department, Royal Hobart Hospital
for their assistance in retrieving the medical records of
patients. Also the Plastics Department who is involved
in the treatment of all multi-facial trauma, David Lees
of The University of Tasmania for his kind assistance
and Mr David Wiesenfeld of The University of
Melbourne for his kind advice.
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Address for correspondence/reprints:

Dr Peter Dongas/Dr Graham M Hall
Oral and Maxillofacial Surgery Unit
Royal Hobart Hospital
Hobart, Tasmania 7000

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