CRANIOMAXILLOFACIAL TRAUMA

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The Epidemiology of Mandibular Fractures 60
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7 in the United States, Part 1: A Review of 62
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9 13,142 Cases from the US National Trauma 65
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11 Data Bank 67
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13 Q6 Paul N. Afrooz, MD,* Michael R. Bykowski, MD,y Isaac B. James, MS,z 69
14 Lily N. Daniali, MD,x and Julio A. Clavijo-Alvarez, MD, PhD, MPHk 70
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Purpose: To date, no studies have analyzed the national demographics of mandibular fractures in the
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17 United States. This report is part 1 of a 2-part series characterizing the modern demographics, epidemi- 73
18 ology, and outcomes of mandibular fractures in the United States. The purpose of this study was to char- 74
19 acterize mandibular fractures in relation to age, gender, mechanism of injury, and anatomic location of 75
20 fracture. 76
21 Material and Methods: A retrospective cohort study was conducted using the National Trauma Data 77
22 Bank (NTDB). The sample was derived from the population of hospitalized patients enrolled in the 78
23 NTDB from 2001 to 2005 using mandibular fracture (International Classification of Diseases, Ninth Revi- 79
24 sion codes 802.21 through 802.39) as an inclusion criterion. Patient- and injury-related variables, including 80
25 age, gender, anatomic location of fracture, and mechanism of injury, were analyzed by Fisher exact and c2 81
26 testing. 82
27 Results: A total of 13,142 patients with mandibular fractures from participating trauma centers were 83
28 included in the study. Eighty percent of patients were male. Fracture distribution by age was roughly 84
29 bell-shaped, with fractures occurring most frequently at 18 to 54 years of age. Mechanism of injury differed 85
30 by gender, with men most often sustaining mandibular fracture from assault (49.1%), followed by motor 86
31 vehicle accidents (MVAs; 25.4%) and falls (12.8%). Women most commonly sustained mandibular fracture 87
32 from MVAs (53.7%), followed by assault (14.5%) and falls (23.7%). Falls were a significantly more common 88
33 mechanism in patients who were at least 65 years old (P < .001). 89
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Conclusion: This study sought to characterize the largest, modern, population-based sample of mandib-
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36 ular fractures in the United States. Overall, men had a 4-fold higher incidence, but this distribution varied 92
37 by age. Similarly, mechanism of injury varied across gender and age range. A better understanding of the 93
38 influence of age and gender on mechanism of injury and anatomic site is of great clinical importance in the 94
39 assessment, diagnosis, and treatment of traumatic mandibular fractures. 95
40 Ó 2015 American Association of Oral and Maxillofacial Surgeons 96
41 J Oral Maxillofac Surg -:1-6, 2015 97
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43 The mandible is one of the most commonly fractured within a given population vary considerably among 99
44 facial bones as a result of maxillofacial trauma.1 The study groups.2-16 To date, there are no studies 100
45 patterns and mechanisms of injury and the distribution analyzing the national demographics of mandibular 101
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47 *Resident, Department of Plastic and Reconstructive Surgery, Address correspondence and reprint requests to Dr Clavijo- 103
48 University of Pittsburgh, Pittsburgh, PA. Alvarez: Aestique Plastic Surgery Associates, Greensburg, PA 104
49 yResident, Department of Plastic and Reconstructive Surgery, 15601; e-mail: julio.clavijo@aestique.com 105
50 University of Pittsburgh, Pittsburgh, PA. Received April 2 2014 106
51 zMedical Student Research Fellow, Department of Plastic and Accepted April 23 2015 107
52 Reconstructive Surgery, University of Pittsburgh School of Ó 2015 American Association of Oral and Maxillofacial Surgeons 108
53 Medicine, Pittsburgh, PA. 0278-2391/15/00492-9 109
54 xResident, Division of Plastic and Reconstructive Surgery, http://dx.doi.org/10.1016/j.joms.2015.04.032 110
55 University of Medicine and Dentistry of New Jersey, Newark, NJ. 111
56 Q5 kAestique Plastic Surgery Associates, Greensburg, PA. 112

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113 fractures in the United States. Furthermore, there is no tion of Diseases, Ninth Revision codes 802.21 169
114 consensus among prior landmark studies regarding through 802.39) were included in the study. Analysis 170
115 the epidemiology and demographics of mandibular was performed using Centers for Disease Control 171
116 fractures. This lack of consensus seems to be a and Prevention cutoff values for age subgroups (0 to 172
117 reflection of epidemiologic and demographic 1, 2 to 4, 5 to 9, 10 to 14, 15 to 17, 18 to 24, 25 to 173
118 variability among reporting trauma centers. As such, 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, 174
119 extrapolation of existing data might not be an and $85 yr). 175
120 accurate representation of national patterns. 176
121 The purpose of this study was to provide an updated VARIABLES 177
122 epidemiologic and demographic report on the largest 178
Each NTDB admission record contains data on pa-
123 sample of mandibular fractures yet reported by data 179
tient demographics, injury mechanism, anatomic site
124 collection from the US National Trauma Data Bank 180
of injury, and hospital outcomes (length of hospital
125 (NTDB). More specifically, the authors sought to char- 181
stay, admission to intensive care unit, length of stay
126 acterize mandibular fractures in relation to age, 182
in intensive care unit, and ventilator requirements).
127 gender, mechanism of injury, and anatomic location 183
Mechanism was classified into motor vehicle accident
128 of fracture. They hypothesized that differences in de- 184
(MVA), motorcycle accident, bicycle injury, pedestrian
129 mographic factors, such as age and gender, would be 185
injury, assault, firearm, and fall. Anatomic location was
130 associated with different mechanisms of injury and 186
classified as symphysis, body, angle, condyle, subcon-
131 anatomic locations of the fracture. 187
dylar, ramus, alveolar, coronoid, or multiple.
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133 Materials and Methods 189
134 DATA ANALYSIS 190
135 STUDY DESIGN AND POPULATION Statistical analyses were performed using Excel 191
136 After obtaining approval from the institutional re- (2002; Microsoft, Redmond, WA) and STATA IC 10 (Sta- 192
137 view board of the University of Pittsburgh (Pittsburgh, taCorp LP, College Station, TX). Discrete variables 193
138 PA), the authors designed and conducted a retrospec- were compared using the Fisher exact test or c2 194
139 tive review of craniofacial injuries in patients enrolled testing. In all cases, P values are reported. 195
140 in the NTDB (http://www.facs.org/trauma/ntdb. 196
141 html). The NTDB contains data on 630,000 patients 197
Results
142 receiving inpatient treatment after trauma as reported 198
143 from more than 600 US trauma centers. GENERAL AND AGE DEMOGRAPHICS 199
144 A total of 13,142 patients with mandibular fractures 200
145 DATA COLLECTION METHODS were identified. Injury was most common in the 18- to 201
146 Patients admitted with mandibular fracture from 24-year-old group, with most cases occurring at 18 to 202
147 2001 to 2005 (identified by International Classifica- 54 years of age (Fig 1). 203
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167 FIGURE 1. Age distribution of mandibular fractures. Q4 223
168 Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral Maxillofac Surg 2015. 224

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 AFROOZ ET AL 3

225 GENDER 281

226 Gender distribution showed a 4-fold higher inci- 282
227 dence of mandibular fractures in men compared 283
228 with women. However, this trend reversed after 284
229 65 years of age, leading to a higher incidence of frac- 285
230 tures in women in the group at least 85 years old 286
231 (P < .001; Fig 2). Interestingly, girls also were more 287
232 likely to sustain mandibular fracture at 5 to 9 years 288
233 old compared with their male counterparts (P < .001). 289
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MECHANISM OF INJURY
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237 Distribution by mechanism of injury is shown in 293
238 Figure 3. Assault was the predominant mechanism of 294
239 injury (42%), followed by motor vehicle accidents 295
240 (MVAs; 31%) and falls (15%). Analyzing the mechanism FIGURE 3. Distribution by mechanism of injury. MVA, motor 296
241 of injury by gender and age showed a male preponder- vehicle accident. 297
242 ance (Fig 4) that was similar to the overall age distribu- Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral 298
243 tion. Similar to men, women showed the highest Maxillofac Surg 2015. 299
244 incidence in the 18- to 24-year-old group (Fig 5). How- 300
245 ever, women were significantly more likely to have 301
mandible. The anatomic areas affected, in order of
246 sustained mandibular fracture secondary to MVAs 302
occurrence, were the symphysis (19.2%), body
247 compared with men (54 vs 25%, respectively; P < 303
(18.1%), angle (16.2%), condyle (14.8%), subcondylar
248 .001). In men and women, falls were more likely to 304
(12.6%), ramus (11.3%), alveolus (4.5%), and coronoid
249 be the primary cause after 65 years of age (P < .001), 305
(3.3%; Fig 6).
250 whereas assaults were significantly more common at 306
The various mechanisms of injury and correlating
251 18 to 54 years of age (P < .001). 307
anatomic fracture sites are shown in Figure 7. Angle
252 fractures were most likely to occur after an assault 308
253 MECHANISM OF INJURY AND ASSOCIATED (P < .001), followed by MVAs (P < .001). Condyle frac- 309
254 ANATOMIC SITE tures were most likely to occur from falls (P < .001), 310
255 followed by MVAs (P < .001). Symphysis fractures 311
The 3 most frequent mechanisms of injury (assault,
256 occurred most frequently after an assault or an MVA 312
MVAs, and falls) were analyzed and correlated with the
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frequency of anatomic areas fractured within the
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279 FIGURE 2. Mandibular fracture distribution by age and gender. 335
280 Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral Maxillofac Surg 2015. 336

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349 FIGURE 4. Mechanism of injury in male patients by age group. 405
MVA, motor vehicle accident.
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351 Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral 407
Maxillofac Surg 2015. FIGURE 6. Anatomic occurrence of mandibular fractures.
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353 Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral 409
354 Discussion Maxillofac Surg 2015. 410
355 Mandibular fractures are among the most common 411
356 facial injuries encountered by facial trauma surgeons, mandibular fractures in male compared with female 412
357 with twice the occurrence rate of midfacial fractures.1 patients. This trend begins to decrease at 65 years 413
358 No studies to date have analyzed a national cohort of and has reversed by 85 years as falls become the pri- 414
359 mandibular fractures across all age groups. Further- mary mechanism of injury. This phenomenon is likely 415
360 more, prior studies lack epidemiologic and demo- the result of the larger proportion of women in the ag- 416
361 graphic consensus owing to the variable patient ing population, compounded by senescent osteopenia 417
362 populations analyzed.2-16 The purpose of this study predisposing the mandible to fracture.17,18 418
363 was to examine a large, modern, diverse population The incongruity seen in previous reports with 419
364 of mandibular fractures and offer a more respect to mechanism of injury reflects the inherent 420
365 generalizable assessment of the demographic factors, variability of patient populations, regional socioeco- 421
366 injury mechanisms, and fracture sites across a wide nomic factors, and referral patterns at individual 422
367 age range. The key findings are that 1) men have a 4- trauma centers.3,4,9 In a landmark study by Ellis 423
368 fold higher incidence of mandibular fractures and 2) et al,3 2,137 mandibular fractures were reviewed 424
369 gender and age are associated with mechanism over a 10-year period from 1974 to 1983 in a western 425
370 of injury. Scottish hospital system. Assault was found to be the 426
371 These data show that most mandibular fractures are most frequent cause of mandibular fractures, followed 427
372 sustained by those in early to middle adulthood (18 to by falls and MVAs. The present study corroborates as- 428
373 54 yr old)—a pattern that has remained stable sault as the most frequent mechanism of mandibular 429
374 throughout the past 3 decades.3,4,6,10 Furthermore, fractures, but the data regarding MVAs and falls differ 430
375 these data show a 4-fold increase in incidence of from those in the report by Ellis et al.3 However, 431
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389 FIGURE 5. Mechanism of injury in female patients by age group. FIGURE 7. Anatomic distribution of mandibular fractures. MVA,
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390 MVA, motor vehicle accident. motor vehicle accident. 446
391 Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral Afrooz et al. Epidemiology of Mandibular Fractures, Part 1. J Oral 447
392 Maxillofac Surg 2015. Maxillofac Surg 2015. 448

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449 a study from Germany evaluating inpatient mandibular sents a unique methodology encompassing national 505
450 fractures found MVAs to be the most common mecha- data across all age groups and from a diverse multi- 506
451 nism of injury.19 This difference in the frequency of institutional population. The authors believe that this 507
452 MVA as the mechanism of mandibular fractures high- large and diverse sample more closely represents the 508
453 lights the variability among study populations and modern epidemiology and demographics of mandib- 509
454 likely represents the more contemporary national ular fractures than data currently available in the 510
455 trend of motor vehicle use in the US population. literature. 511
456 Women differed from men by a higher incidence of Men sustained mandibular fractures at a rate 4 times 512
457 mandibular fractures as a result of MVAs at middle age that of women. Overall, most mandibular fractures 513
458 and falls at older ages. This pattern is obscured in the occurred at 18 to 54 years old. The overall leading 514
459 overall analysis of mechanism of injury owing to the mechanisms of injury were assaults, MVAs, and falls. 515
460 increased ratio of affected men to women—a pattern When taken as a whole, mandibular fractures most 516
461 not reported in previous studies. Ellis et al3 found often occur within the symphysis and condylar and 517
462 that assault was the most frequent mechanism of subcondylar regions, mirroring the anatomic distribu- 518
463 injury, followed by falls and MVAs in men and women. tion most often seen with assault. Women were more 519
464 In addition, other studies have reported gunshot often affected by MVAs—a high-energy mechanism, 520
465 wounds as a common mechanism of injury.9 This vari- which has implications for clinical outcome as dis- 521
466 ability further suggests that the mechanism of injury is cussed in part 2 of this series. Q3 522
467 influenced by several factors, including the socioeco- 523
468 nomic demographic of the study population, high- 524
469 lighting the need for proactive evaluation of a given References 525
470 population in an effort to identify targets for potential 1. Kelly DE, Harrigan WF: A survey of facial fractures: Bellevue 526
471 preventative education through age- and gender- Hospital, 1948-1974. J Oral Surg 33:146, 1975 527
472 specific campaigns. 2. Atanasov DT: A retrospective study of 3326 mandibular frac- 528
tures in 2252 patients. Folia Med (Plovdiv) 45:38, 2003
473 Several studies have correlated anatomic fracture 3. Ellis E III, Moos KF, el-Attar A: Ten years of mandibular fractures: 529
474 sites within the mandible to mechanism of An analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol 59: 530
475 injury.3,9,15,16,20 Ellis et al3 found that assault most 120, 1985 531
4. Erol B, Tanrikulu R, Gorgun B: Maxillofacial fractures. Analysis
476 frequently affected the angle and body of the of demographic distribution and treatment in 2901 patients 532
477 mandible. The present study corroborates these find- (25-year experience). J Craniomaxillofac Surg 32:308, 2004 533
478 ings and identifies major involvement of the mandib- 5. Eskitascioglu T, Ozyazgan I, Coruh A, et al: Retrospective anal- 534
ysis of two hundred thirty-five pediatric mandibular fracture
479 ular symphysis. This can be explained by the classic cases. Ann Plast Surg 63:522, 2009 535
480 coup-countercoup type of injury that typically occurs 6. Falcone PA, Haedicke GJ, Brooks G, et al: Maxillofacial fractures 536
481 in mandibular fractures as impact force is distributed in the elderly: A comparative study. Plast Reconstr Surg 86:443, 537
1990
482 through the bony arch. In addition, the authors found 7. Ferreira PC, Amarante JM, Silva AC, et al: Etiology and patterns of 538
483 that symphysis, condyle, and angle fractures occurred pediatric mandibular fractures in Portugal: A retrospective study 539
484 with the highest incidence as a result of MVAs. of 10 years. J Craniofac Surg 15:384, 2004 540
8. Fridrich KL, Pena-Velasco G, Olson RA: Changing trends with
485 Although this finding differs from the report by Ellis mandibular fractures: A review of 1,067 cases. J Oral Maxillofac 541
486 et al, it is likely a much more accurate representation Surg 50:586, 1992 542
487 of a modern nationwide population more dependent 9. King RE, Scianna JM, Petruzzelli GJ: Mandible fracture patterns: 543
A suburban trauma center experience. Am J Otolaryngol 25:301,
488 on motor vehicle transportation that is far more prone 2004 544
489 to MVAs. It also more accurately reflects patterns of 10. Larsen OD, Nielsen A: Mandibular fractures. I. An analysis of 545
490 mandibular fracture in vehicles designed with contem- their etiology and location in 286 patients. Scand J Plast 546
Reconstr Surg 10:213, 1976
491 porary airbag safety and passenger restraint systems. 11. Lee KH: Epidemiology of mandibular fractures in a tertiary 547
492 Age also appears to affect anatomic location of frac- trauma centre. Emerg Med J 25:565, 2008 548
493 Q2 ture. Smith et al reported that in a level 1 metropolitan 12. Martini MZ, Takahashi A, de Oliveira Neto HG, et al: Epidemi- 549
ology of mandibular fractures treated in a Brazilian level I trauma
494 pediatric trauma center, condylar head and neck frac- public hospital in the city of Sao Paulo, Brazil. Braz Dent J 17: 550
495 tures accounted for 52.5% (26 and 26.5%, respec- 243, 2006 551
496 tively) compared with the present adult cohort of 13. Melmed EP, Koonin AJ: Fractures of the mandible. A review of 552
909 cases. Plast Reconstr Surg 56:323, 1975
497 27.4% when condyle and subcondylar fractures 14. Murray JF, Hall HC: Fractures of the mandible in motor vehicle 553
498 are combined. accidents. Clin Plast Surg 2:131, 1975 554
499 Limitations to this study include selection bias 15. Ogundare BO, Bonnick A, Bayley N: Pattern of mandibular frac- 555
tures in an urban major trauma center. J Oral Maxillofac Surg 61:
500 toward more severe traumatic injury because the 713, 2003 556
501 data represent an inpatient database. Patients with 16. Salem JE, Lilly GE, Cutcher JL, et al: Analysis of 523 mandibular 557
502 mandibular fractures evaluated acutely that do not fractures. Oral Surg Oral Med Oral Pathol 26:390, 1968 558
17. Bollen AM, Taguchi A, Hujoel PP, et al: Case-control study on self-
503 require hospital admission are not represented in reported osteoporotic fractures and mandibular cortical bone. 559
504 this report. Nevertheless, sampling the NTDB repre- Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:518, 2000 560

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561 18. Hohlweg-Majert B, Schmelzeisen R, Pfeiffer BM, et al: Signifi- etiology, treatment, and complications. J Oral Maxillofac Surg 565
cance of osteoporosis in craniomaxillofacial surgery: A review 67:1251, 2009
562 566
of the literature. Osteoporos Int 17:167, 2006 20. Motamedi MH: An assessment of maxillofacial fractures: A
563 19. Bormann KH, Wild S, Gellrich NC, et al: Five-year retrospective 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 567
564 study of mandibular fractures in Freiburg, Germany: Incidence, 2003 568

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