Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e165ee169

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Journal of Cranio-Maxillo-Facial Surgery

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Aetiology and incidence of maxillofacial trauma in Amsterdam: A retrospective

analysis of 579 patients
Bart van den Bergha, K. Hakki Karagozoglua, Martijn W. Heymansb, Tymour Forouzanfara, *
a
Department of Oral and Maxillofacial Surgery/Pathology Academic Centre for Dentistry Amsterdam (ACTA) and VU University Medical Center, P.O. Box 7057, 1007 MB,
Amsterdam, The Netherlands
b
Department of Epidemiology and Biostatistics, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The incidence of maxillofacial fractures varies widely between different countries. The large
Paper received 21 December 2010 variability in reported incidence and aetiology is due to a variety of contributing factors, including envi-
Accepted 13 August 2011 ronmental, cultural and socioeconomic factors. This retrospective report presents a study investigating the
aetiology and incidence of patients with maxillofacial fractures in Amsterdam over a period of 10 years.
Keywords: Results: The study population consisted of 408 males and 171 females with a mean age of 35.9
Maxillofacial trauma
(SD:
16.3) years. The age group 20e29 years accounted for the largest subgroup in both sexes. The most
Maxillofacial surgery
common cause of the fractures was traffic related, followed by violence. There were mainly mandibular
Incidence
Prevalence
and zygomatic bone fractures in both males and females, accounting for approximately 80% of all frac-
Western-Europe tures. The main fracture site of the mandible was the combination of mandibular body with mandibular
condyle (66 patients; 26.8%), followed by the combination of bilateral condylar fracture and fracture of
the symphysis (43 patients; 17.5%). In fractures of the upper 2/3 of the face, zygomatic bone fractures
were most common. In patients with alcohol consumption the injury was mostly the result of violence.
In conclusion, this report provides important data for the design of plans for injury prevention, as
compared with previous studies. Violence related injuries are increasing whereas fractures caused by
traffic accidents are decreasing.
Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction
Facial fractures are the result of various types of trauma to the
face, and may occur in isolation or combined with other injuries
(Erdmann et al., 2008). Diagnosis and treatment of facial fractures
remains a challenging problem that frequently requires a multi-
disciplinary approach (Erdmann et al., 2008; Katzen et al., 2003).
The incidence of maxillofacial fractures varies widely between
different countries (Al Ahmed et al., 2004). The main causes
worldwide are traffic accidents, assaults, falls and sport injuries
(Ellis, III et al., 1985; Gassner et al., 2003; Lee et al., 2010; Motamedi,
2003). Studies performed in countries like Singapore, New Zealand,
Denmark, Japan and the Middle East region have shown that motor
vehicle crashes are the most common cause of maxillofacial frac-
tures in those countries, whereas in less economically advanced
countries like parts of sub-Saharan Africa and South Africa maxil-
lofacial injuries are more often the result of interpersonal violence
in the form of fights, assaults and gunshots (Aksoy et al., 2002; Lee
et al., 2010). The large variability in reported incidence and aeti-
ology is due to a variety of contributing factors, including envi-
ronmental, cultural and socioeconomic factors (Al Ahmed et al.,
2004; Bakardjiev and Pechalova, 2007; Lee et al., 2010; van Beek
and Merkx, 1999). Some studies describe a decrease in road traffic
accidents, and an increase in interpersonal violence due to alcohol
abuse and growing aggression in the society (de Matos et al., 2010;
Lee, 2009a; van Beek and Merkx, 1999).
To our knowledge there is a lack in reports detailing the causes
and incidence of maxillofacial trauma in The Netherlands. This
retrospective report presents a study investigating the aetiology
and incidence of patients with maxillofacial fractures in Amster-
dam over a period of 10 years.

2. Materials and methods

* Corresponding author. Department of Oral and Maxillofacial Surgery/Oral
Pathology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The
Netherlands. Tel.: þ31204441031. The hospital and outpatient records of 579 patients treated for
E-mail address: t.forouzanfar@vumc.nl (T. Forouzanfar). maxillofacial trauma from January 2000 to January 2010, were

1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
doi:10.1016/j.jcms.2011.08.006
e166 B. van den Bergh et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e165ee169

reviewed and analysed retrospectively. The patients were identified
using the hospital database. Patients with all types of maxillofacial
fractures that were treated surgically by open or closed reduction
were included. Patients with dentoalveolar and nose fractures were
excluded, as these patients are mostly treated by dentists and the
department of ENT of our hospital respectively. Data collected
included sex, age, cause of injury, type of maxillofacial trauma,
alcohol consumption, drug (ab)use, treatment modality and
complications.
The maxillofacial fractures were subdivided into zygomatic
fractures (fracture of the zygomatic complex or zygomatic arch),
mandibular fractures (fracture of the mandibular condyle,
mandibular angle or mandibular body), blow-out fractures, Le Fort
I/II/III fractures, fracture of the frontal sinus, panfacial trauma and
multitrauma (combination of fractures).
2.1. Statistics
Data were processed using the Statistical Package for Social
Sciences (SPSS) version 15.0. For parametric data Student t-test and
for non-parametrics Chi-square tests were performed.
3. Results
3.3. Mandibular fractures
In Table 3 the mandibular fractures are listed according to the
cause of injury. A total of 246 patients with mandibular fractures
were identified. The main fracture site was the combination of
mandibular body with mandibular condyle (66 patients; 26.8%),
followed by the combination of bilateral condylar fracture and
fracture of the symphysis (43 patients; 17.5%). A list of causes is
given for the group of angle fractures (20 patients; 8.1%), body
fractures (36 patients; 14.6%) and a combination of angle and
body fracture (32 patients; 13.0%). A group of 49 patients
remained containing types of fractures which occur less
frequently (e.g. combined bilateral angle with a bilateral body
fracture or a combination of a bilateral body and unilateral
condyle fracture).
The fractures were mainly caused by traffic accidents (34.5%),
with bicycle accidents being most common followed by violence
with 27.2%. Violence related trauma proved to be a significant
cause of injury in patients with angular fractures and angular
fractures combined with mandibular body fractures (P < 0.01). In
patients with a combination of bilateral condylar fracture and
fracture of the symphysis bicycle accidents were the most
common cause (P < 0.01).

3.1. Fracture and injury cause according to gender 3.4. Fractures of the 2/3 upper face

The study population consisted of 408 males and 171 females
with a mean age of 35.9 (SD:
16.3) years. The youngest patient
was 2 years and the oldest 88 years. There was no significant
difference in age between male and female patients.
As shown in Table 1a and 1b there were mainly mandibular and
zygomatic bone fractures in both males and females accounting for
approximately 80% of all fracture sites. No differences between
male and female patients were noted.
In both groups traffic accidents were the main cause of injury
(Table 2a and 2b), followed by violence for the male patients (27.7%)
and falls for the females (19.9%). Significantly more males than
females were treated for fractures caused by violence and sports
(P < 0.01). Dividing the traffic accidents by mode of transport,
bicycle and automobile accidents resulted in significantly more
injuries in female patients when compared to males (P < 0.01).
3.2. Fracture and injury according to age classification
The age group 20e29 years accounted for the largest subgroup
in both sexes (30.1% of the males, 26.3% of the females). In the male
patients between 20e49 years violence and traffic accidents were
equally divided and formed the main cause of the fractures,
whereas in the female population traffic accidents were signifi-
cantly higher compared with the other causes in patients between
20e49 years (P < 0.05). In patients of 50 years and older the injuries
were mostly a result of traffic accidents and falls (Table 2a and 2b).
In this study there were 333 patients with fractures of the 2/3
upper face. In Table 4 these fractures are listed according to the
cause of injury. Zygoma fractures were most common (64.3%),
followed by panfacial fractures and midface fractures (Le Fort I/II/III
and combined midfacial fractures). As in mandibular fractures,
except for zygomatic arch fractures and panfacial trauma, traffic
accidents were the main cause of injury, followed by violence.
Isolated zygomatic arch fractures were mostly the result of violence
and sports related trauma. Panfacial trauma was most often the
result of traffic accidents.
3.5. Alcohol consumption
Concerning alcohol consumption the data of 135 patients were
missing. Of the remaining 444 patients 79 had used alcohol before
the injury (Table 5).
Pearson Chi-square demonstrated significant differences
(P < 0.01) between women and men. The values of Phi, Cramer’s V
and the Contingency coefficient were under 0.3, therefore
although the relationship is not due to chance, it is also not very
strong.
Facial injury was mostly the result of violence as shown in Fig. 1.
Compared to other causes this difference proved to be significant
(P < 0.05). There was no significant difference in the cause of injury
in patients who used alcohol or in those that did not.

Table 1a
Facial fractures according to age for male patients.

Age Mandible Zygomatic Le Fort Panfacial Multitrauma Blow-out Frontal sinus Zygomatic Total (%)
complex arch
0e9 2 2 1 5 (1.2)
10e19 31 9 2 3 1 2 48 (11.8)
20e29 57 38 2 2 11 6 7 123 (30.1)
30e39 40 34 2 2 4 1 8 91 (22.3)
40e49 24 32 3 2 13 3 1 4 82 (20.1)
50þ 16 34 2 2 3 1 1 59 (14.5)
Total 170 149 11 8 34 6 11 19 408
(%) (41.6) (36.5) (2.7) (2.0) (8.3) (1.5) (2.7) (4.7)
 B. van den Bergh et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e165ee169 e167

Table 1b
Facial fractures according to age for female patients.

Age Mandible Zygomatic Le Fort Panfacial Multitrauma Blow-out Frontal Zygomatic Total (%)
complex sinus arch
0e9 3 1 4 (2.3)
10e19 12 4 1 2 19 (11.1)
20e29 26 13 2 1 1 2 45 (26.3)
30e39 14 10 1 2 3 3 1 34 (19.9)
40e49 9 17 1 27 (15.8)
50þ 12 20 2 1 3 3 1 42 (24.6)
Total 76 65 4 6 9 6 2 3 171
(%) (44.4) (38.0) (2.3) (3.5) (5.3) (3.5) (1.2) (1.8)

Table 2a
Cause of injury according to age for male patients.

Age Fall Violence Pedestrian Bicycle Motorcycle Automobile Sports Suicide Others Missing Total %
hit accident accident accident attempt file
0e9 1 1 1 1 4 (1.0)
10e19 8 13 2 6 11 2 1 5 48 (11.8)
20e29 15 39 13 14 8 17 1 3 13 123 (30.1)
30e39 13 28 11 10 8 15 1 2 4 92 (22.5)
40e49 10 23 12 5 3 7 1 9 11 81 (19.9)
50þ 18 9 1 14 5 2 3 3 5 60 (14.7)
Total 64 113 4 57 45 23 43 3 17 39 408
(%) (15.7) (27.7) (1.0) (14.0) (11.0) (5.6) (10.5) (0.7) (4.2) (9.6)

Table 2b
Cause of injury according to age for female patients.

Age Fall Violence Pedestrian Bicycle Motorcycle Automobile Sports Suicide Others Missing Total (%)
hit accident accident accident attempt file
0e9 4 1 5 (2.9)
10e19 3 5 2 3 2 1 2 1 19 (11.1)
20e29 3 7 18 3 3 1 1 9 45 (26.3)
30e39 3 4 1 10 2 8 1 1 3 33 (19.3)
40e49 6 2 9 3 3 1 2 1 27 (15.8)
50þ 16 3 2 13 1 2 5 42 (24.6)
Total 35 16 3 55 11 19 5 2 5 20 171
(%) (19.9) (9.4) (1.8) (32.2) (6.4) (11.1) (2.9) (1.2) (2.9) (12.3)

Table 3
Mandibular fractures according to cause of injury.

Fracture site Fall Violence Pedestrian Bicycle Motorcycle Automobile Sport Suicide Others Missing Total (%)
hit accident accident accident attempt
B1 þ C2 10 17 1 14 5 5 5 2 7 66 (26.8)
BþCþC 12 2 20 4 5 43 (17.5)
B 7 3 6 2 4 9 5 36 (14.6)
A3 þ B 3 18 1 2 4 1 3 32 (13.0)
A 3 11 1 1 1 1 1 1 20 (8.1)
Other combinations 13 16 6 4 3 2 1 4 49 (19.9)
Total 48 67 2 49 20 14 17 1 3 25 246
(%) (19.5) (27.2) (0.8) (19.9) (8.1) (5.7) (6.9) (0.4) (1.2) (10.2)
1
B: Body; 2C: Condyle; 3A: Angle.

Table 4
Fractures of the upper 2/3 of the face according to cause of injury.

Fracture site Fall Violence Pedestrian Bicycle Motorcycle Automobile Sport Suicide Others Missing Total (%)
hit accident accident accident attempt
Zygoma 36 38 3 47 25 17 23 9 16 214 (64.3)
Panfacial 8 4 2 9 5 2 1 3 2 3 39 (11.7)
Midface 2 10 4 3 6 1 1 6 33 (9.9)
Solitary arch 7 2 1 6 2 4 22 (6.6)
Frontal sinus 2 2 2 1 1 2 3 13 (3.9)
Blow out 2 2 2 3 3 12 (3.6)
Total 50 63 5 62 36 28 31 4 19 35 333
(%) (15.0) (18.9) (1.5) (18.6) (10.8) (8.4) (9.3) (1.2) (5.7) (10.5)
e168 B. van den Bergh et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e165ee169

Table 5 condyle or body fracture. In patients with upper 2/3 face fractures,
Cause of injury listed according to alcohol consumption. zygomatic bone fractures were most common, mainly caused by
Injury cause Alcohol consumption traffic accidents. Isolated zygomatic arch fractures were the result
Yes No Total
of violence and sports. In patients with alcohol consumption facial
injury was mostly the result of interpersonal violence. The results of
Fall 12 65 77
Violence 33 83 116 the Iida study demonstrated that in elderly women the facial
Pedestrian hit 1 4 5 injuries are mostly caused by falls, which is in line with the present
Bicycle accident 22 76 98 study (Iida et al., 2001).
Motorcycle accident 8 40 48
The decrease of road traffic accidents as a cause of facial frac-
Automobile accident 3 29 32
Sports 46 46
tures in the EU is the result of preventive measures, such as the
Suicide 4 4 obligatory wearing of crash helmets, the seat belt and the more
Other 18 18 aggressive enforcement of the law regarding “drinking and driving”
Total 79 365 444 (van Beek and Merkx, 1999). Van Beek et al. showed in their
(%) (17.8) (82.2)
longitudinal study that during a time period of 20 years traffic
Missing data: 135. accident related facial fractures decreased whereas violence related
fractures increased (van Beek and Merkx, 1999). Comparing our
study with the study of van Beek et al., the trend of decreasing
traffic accident related facial injury and increased fractures caused
by violence can be noted (van Beek and Merkx, 1999).
The present study has several shortcomings. In Amsterdam
there are four hospitals of which two are university hospitals. All
hospitals treat patients with facial injury, however some see more
patients than others. Most patients are treated in the two university
hospitals. Therefore it is questionable if the results of our study can
be extrapolated to the whole population of Amsterdam. Further-
Fig. 1. Patients with alcohol consumption listed according to cause of injury.
more, like other retrospective studies this retrospective analysis
may be subject to information bias. However, the results presented
are in line with other studies and the analysis of this report
4. Discussion provides important data for the design of plans for injury preven-
tion and concurs with previous studies that violence related
Maxillofacial fractures are one of the most common injuries and injuries are increasing whereas fractures caused by traffic accidents
can be challenging to diagnose and treat. (Erdmann et al., 2008; are decreasing.
Katzen et al., 2003; Lee et al., 2010; Motamedi, 2003) The cause
of facial injuries depends on a variety of contributing factors,
5. Conclusion
including environmental, cultural and socioeconomic factors.
(Al Ahmed et al., 2004; Ellis, III et al., 1985; Iida et al., 2001;
The results of this retrospective study provide important data
van Beek and Merkx, 1999).
for the design of future plans for injury prevention. Mandibular and
Several studies have reported that facial bone injuries are
zygomatic bone fractures remain the most frequent fractures. The
mostly the result of traffic accidents and violence. (Al Ahmed et al.,
trend of increasing violence related injuries and decreasing traffic
2004; Bakardjiev and Pechalova, 2007; de Matos et al., 2010;
related injuries continues. In Amsterdam bicycle accidents are
Dimitroulis and Eyre, 1991; Ellis, III et al., 1985; Iida et al., 2001;
a major cause of maxillofacial trauma.
Scherer et al., 1989; van Beek and Merkx, 1999).
This study describes the epidemiology of 579 patients with
Ethical approval
facial injury. The male female ratio was 2.4:1. Mandibular and
Not required.
zygomatic bone fractures were the main fractures, accounting for
80% of all fracture sites. The highest rate of incidence of fractures Funding
was caused by traffic accidents, with bicycle accidents being the None.
most common aetiology, followed by violence especially in males.
Competing interests
When comparing males to females, violence related fracture
None declared.
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