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Keywords:

  • Alcohol;
  • facial trauma;
  • IPV;
  • mandible fracture

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Background:  Alcohol as a cofactor in interpersonal violence (IPV) has been established by studies from a number of countries. This study aimed to determine if alcohol was a cofactor in the incidence or severity of mandible fracture.

Methods:  A prospective study of mandible fracture patients presenting for oral maxillofacial review over 16 months was completed. Injury severity was assessed utilizing the Mandible Injury Severity Score (MISS).

Results:  A total of 252 facial trauma cases presented to our tertiary referral centre, 83 with fractures of the mandible. The majority of presentations were secondary to IPV (n = 54, 65.06%), 49 (90.74%) of these cases involved alcohol. Overall, alcohol was involved in 63.85% of cases (n = 53). The relative risk of requiring surgical intervention with alcohol involvement was 2.68 (CI = 1.11–9.47). Alcohol significantly increased facial fracture severity for MISS: alcohol (n = 53) 13.07 ± 5.01, no alcohol (n = 30) 11.03 ± 4.87 (p < 0.05). IPV also increased facial fracture severity for MISS: IPV (n = 54) 13.09 ± 4.90, non-IPV (n = 29) 11.00 ± 4.81 (p < 0.05). The angle of the mandible was most commonly fractured (40.5% of cases).

Conclusions:  Mandible fracture patients, whose injury is a result of IPV, have more severe fractures and a higher likelihood of requiring surgery if alcohol is involved. This correlates to a higher surgical workload, economic and social burden to the community. Primary alcohol and IPV prevention strategies will play an important role in reducing mandible fracture.


Abbreviations and acronyms:
IPV

interpersonal violence

MISS

Mandible Injury Severity Score

MVA

motor vehicle accidents

OMF

oral-maxillofacial

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

The mandible is an anatomically prominent and mobile component of the facial skeleton, which places it at risk of injury in the event of facial trauma. Its functional role in respiration, vocalization and swallowing, and its importance in facial aesthetics may mean that its fracture could lead to significant morbidity for the patient. Recent evidence also suggests that individuals who suffer mandible fracture and undergo surgical intervention are at increased risk of developing depression.1

Alcohol consumption characteristics are changing, with an increase in the propensity for intermittent high consumption, commonly known as ‘bingeing’, in Australian adolescents.2 Bingeing is associated with significantly higher levels of violence and other harm related behaviour; this pattern of consumption might result from point of sale restriction and social conventions.3

The association between alcohol, interpersonal violence (IPV) and mandible fractures has been well documented.4,5 We believe that mandible fracture severity increases in incidents involving alcohol and IPV. The objective of this study was to determine the aetiology and demographics of mandible fractures, secondary to trauma, presenting to an Australian tertiary referral centre, and whether alcohol involvement or IPV increased injury severity and risk of surgical intervention.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

A prospective study of oral-maxillofacial (OMF) trauma patients treated over 16 months was conducted. A total of 252 patients presented to The Canberra Hospital (ACT, Australia) for assessment. Males represented 80.5% (n = 203) of cases, females 19.5% (n = 48), ages ranging from 1 to 95 years with a median age of 25 and a mean age of 31.22 (± 19.22) years.

Australian adolescents, from early to mid teens, have been identified to commence hazardous alcohol consumption associated with a variety of harms.6 Consequently, study inclusion was set at 15 years of age. Cases where the primary presenting injury was soft tissue trauma, or facial fracture not including a mandible fracture, were excluded. In total, n = 171 (67.06%) of the total presentations were excluded (including two cases of mandible fracture which were younger than the study inclusion age). Of the 83 suitable cases, males represented 90.36% of cases (n = 75), females 9.64% (n = 8), with a median age of 24 and a mean age of 27.06 (± 11.83) years.

On presentation to hospital, an alcohol history was taken. Patients were asked whether they had consumed alcohol within the eight hours prior to the incident and the volume and pattern of consumption was recorded. Patients who responded positively were allocated to the ‘alcohol’ study group. Patients who responded negatively were allocated to the ‘no alcohol’ study group.

Two determinants of injury severity were utilized. The first was the requirement for surgical intervention as a primary treatment modality. The second determinant utilized was the Mandible Injury Severity Score (MISS), described by Shetty et al.,7 which scores the severity of patient mandible fractures by the ‘sum of’ FLOSID (Fracture type, Location, Occlusion, Soft tissue involvement, Infection and Displacement) (Fig 1).

image

Figure 1.  Mandible Injury Severity Score (MISS). (Image courtesy of Elsevier.)

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Mandible Injury Severity Score calculation for clinical presentations

The 83 facial fracture cases were numbered 1 to 83 and de-identified. For each case, relevant analysis details including physical examination and imaging results were collated with appropriate imaging, in a PowerPoint presentation with no indication of whether alcohol was involved or IPV was the mechanism of trauma. This de-identified data was randomly examined three times by a medical officer (trained in advance in the use of the severity scoring technique, and scored according to the descriptions of injury severity and scoring criteria displayed in Fig 1) not involved in the patients’ care. These results were corroborated by a panel of three OMF and two dental surgeons. The final score for analysis was derived from the mean of these scores.

Bone injury severity was determined by review of patient plain X-ray films or computed tomography. If imaging was unobtainable, medical records were reviewed to obtain records of bone injury. Identification of the severity of soft tissue injury, presence of infection, malocclusion and displacement were based on medical records of physical examination. All medical officer team reviews (i.e. emergency, OMF or surgical sub-specialty) of a presentation were analysed. However, measures of malocclusion, displacement and injury type were obtained from OMF review if differing opinions of injury/type were present.

Statistical analysis

To determine whether alcohol contributed to mandible injury severity, all mandible fracture presentations involving alcohol (n = 53) were compared to all OMF trauma presentations not involving alcohol (n = 30). Data are presented as the mean ± one standard deviation of the mean (μ ± 1SD). The Fisher (F-test) was utilized to determine if there was a significant difference between the variance of the two samples, after which a one-tailed t-test (assuming unequal variances) was conducted to determine statistical difference (p < 0.05) between group means (alcohol vs no-alcohol and IPV vs non-IPV) (Table 1).

Table 1.   MISS for mandible fracture cases involving and not involving alcohol, and cases secondary to IPV vs non-IPV
GroupNScore rangeMISS (SD)Significance
Alcohol535–2313.07 ± 5.010.028
No alcohol302–1811.03 ± 4.87 
GroupNScore rangeMISS (SD)Significance
IPV543–2313.09 ± 4.900.032
Non-IPV292–2211.00 ± 4.81

Relative risk calculation

To determine whether alcohol increases the relative risk (RR) of requiring surgical intervention for OMF trauma, the risk of exposed (surgery)/risk of unexposed (nil surgery), for disease (alcohol or IPV involvement) was calculated.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Of the 252 OMF trauma presentations for the defined study period, IPV was the most common aetiology, representing (45.24%) cases, (88.59%) of these presentations involving alcohol. Alcohol did not feature as prominently for motor vehicle accidents (MVA) (29.17%), falls (20%) or sport-related presentations (4.34%) (Fig 2).

image

Figure 2.  Aetiology of mandible fracture presentations and number of presentations involving alcohol. (Solid bars = involved alcohol, open bars = no alcohol involved.)

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Eighty-three mandible fractures presented for OMF review within the defined study period. Most cases were secondary to IPV (n = 54), which represented 65.06% of mandible fracture case load, 49 (90.74%) of these cases involving alcohol. Mandible fractures resulting from sport increased during the winter months and were predominately associated with ‘contact sports’ (rugby and Australian football). One sporting case involved alcohol and occurred during a non-official sporting event not played on a sports field. Motor vehicle accidents resulted in eight mandible fractures (9.6%), two of these cases involving alcohol, although it is important to note that patients may be reluctant to admit to alcohol consumption and subsequently this proportion may actually be higher. Only 40% (n = 2) of falls involved alcohol. However, the average age of presentation for this aetiology was older – many of these being falls in nursing home patients resulting in predominately endentulous mandible fractures which were treated conservatively. In contrast to ‘all OMF presentations for facial trauma’, there were no mandible fractures that presented for aetiologies other than the defined.

Almost all IPV-related mandible fracture presentations involving alcohol required surgical intervention (n = 51, 96.22%) compared with 50% of IPV cases not involving alcohol (n = 4). Alcohol involvement in mandible fracture presentation for OMF review increased the relative risk of requiring surgical intervention by 2.68 (CI 1.11–9.47). The risk of surgical intervention also marginally increased if patients were involved in IPV in comparison to all other presentations for mandible fracture (1.26, CI 0.77–2.97) (Fig 3).

image

Figure 3.  Relative risk of requiring surgical intervention if alcohol and IPV are involved in mandible fracture presentation.

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The MISS identified that presentations where alcohol was involved resulted in a mean mandible fracture injury severity score significantly greater than cases not involving alcohol. When MISS for IPV was compared with non-IPV (for all other aetiologies), injury severity also significantly increased (Table 1).

Results identified that a greater number of unilateral and bilateral mandible fractures were associated with alcohol. IPV was also more likely to result in angle fractures, 65.38% (as a percentage of cases for the given aetiology), while sport-related mandible fractures resulted in a greater proportion of parasymphysis fractures (55.56%).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

In this study, we identified that alcohol consumption increases mandible fracture severity, and also increases the relative risk of requiring surgical intervention for mandible fracture when compared to common aetiologies not involving alcohol. We also demonstrated that IPV increased mandible fracture severity compared to non-IPV aetiologies.

Research has indicated that younger people drink excessive quantities of alcohol for enhancement, enjoyment motives or social facilitation.8 The effect on the central nervous system has been shown to have concurrent detrimental affects. Pihl and Hoaken9 reported that alcohol may reduce fear and anxiety about social, physical or legal consequences of one’s actions – potentially clouding the judgement of someone who normally can reflect on the outcomes of a violent encounter. It has also been shown10–13 that consumption of five or more drinks on one occasion is a separate predictor for IPV involvement.

This is of concern in Australia: a recent national survey indicated that more than 70% of people aged 14 years and older are current drinkers14 and McBride et al.6 found that young Australians (14–19 year olds) are more likely to drink at hazardous or high-risk levels than any other age group, and more than 66% of young Australians drink at these high levels.

Patients with facial injuries as a consequence of injury or assault often have difficulty returning to their previous activities.15 They can experience marital problems, depression, anxiety, addiction, problems with body image, post-traumatic stress disorder and poor satisfaction with life.16,17

The proportion of mandible fractures attributable to IPV in Australia is also a concern. Table 2 outlines a representative sample of studies on mandible fracture presentations, but is by no means exhaustive. A number of studies in Australia indicate a higher proportion of mandible fractures being caused by IPV in comparison to other countries.

Table 2.   Recent studies on IPV and alcohol association with mandible fracture
CountryAuthorNIPVAlcohol
TurkeyOzkaya et al.,1821619.4% 
IndiaBither et al.,1932420.68% 
Australia (Qld)Oberdan et al.,2044474% 
NigeriaOji et al.,21900 8.4% 
USAKing et al.,2213435.1% 
Australia (Tas)Dongas et al.,2325155%41.4%
UKAsadi et al.,24 74% 
This study (ACT)O’Meara et al., 20118365.06%63.85%

Mandible surgical procedures have many intrinsic risks and costs. Complications that may arise as a result of mandible fracture repair include wound infection, malocclusion, nonunion, malunion, tooth loss, trismus, ankylosis, deviation, scars, paraesthesias, failed procedures, re-operation, hardware removal, chronic pain and functional deficit.25–28 It also causes significant economic expense secondary to procedural costs and patient time off work and associated income loss. The association between reduced quality of life and facial trauma is well known.29,30

Consequently, proactive community and education programmes on the consequences of binge drinking and implementation of effective interventions (taxation policy, regulation of all production and sale, content-restricted advertisements and bans on sponsorship), similar to those imposed on the tobacco industry, may aid in reducing IPV-related mandible fracture.

Further research will explore the economic cost of facial fracture associated with alcohol and IPV and the psychological effects of this trauma. We also aim to determine why IPV results in greater injury severity than other common aetiologies of OMF trauma and whether incidences involving alcohol and IPV result in increased complication rates.

A limitation of this study was the subjective measurement of intoxication. Although previous research has determined that patient statement of alcohol consumption is reliable it does not enable analysis of the level of intoxication at the time of incident. Screening for alcohol consumption in the previous eight hours is also a poor measure of consumption patterns and does not consider whether the patient had one standard drink at the start of the eight-hour time period (and therefore likely to have metabolized the ethanol) or whether they have had greater than 10 standard drinks. The study also did not control for ethnicity (people of some ethnic lineages are known to metabolize ethanol at varying rates). Further study will incorporate the use of a breathalyzer, utilized concurrently with patient statement of consumption over time.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References

The association between alcohol and IPV is well known. We have determined that alcohol consumption correlates with an increase in the severity of mandible fracture injuries in patients who have sustained IPV, and this correlated to a higher surgical workload, hospital admission and social burden to the community.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusions
  8. References