Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation

Temporomandibular joint degenerative changes following mandibular fracture: a computed tomography-based study on the role of condylar involvement

OBJECTIVES

This study assessed the incidence of postfracture radiological temporomandibular joint (TMJ) degeneration in patients with different types of mandibular fractures, focusing on the impact of condylar fractures.

METHODS

This retrospective review included patients diagnosed as having mandibular fractures from 2016 to 2020 who had undergone initial computed tomography (CT) and a follow-up CT scan at least 1-month postfracture. Patient demographics, fracture details, treatment methods, and radiological signs of TMJ degeneration on CT were analyzed to identify risk factors for postfracture TMJ degeneration, with a focus on condylar head fracture and non-head (condylar neck or base) fractures.

RESULTS

The study included 85 patients (mean age: 38.95 ± 17.64 years). The per-patient analysis indicated that the incidence of new radiologic TMJ degeneration on CT was significantly the highest (p < 0.001) in patients with condylar head fractures (90.91%), followed by those with non-head condylar fractures (57.14%), and those without condylar involvement (24.49%). The per-joint analysis indicated nearly inevitable degeneration (93.94%) in 33 TMJs with ipsilateral condylar head fractures. For the remaining 137 TMJs, multivariate logistic regression revealed that other patterns (ipsilateral non-head, contralateral, or both) of condylar fractures (odds ratio (OR) = 3.811, p = 0.007) and the need for open reduction and internal fixation (OR = 5.804, p = 0.005) significantly increased the risk of TMJ degeneration.

CONCLUSIONS

Ipsilateral non-head condylar fractures and contralateral condylar fractures are associated with a high risk of postfracture TMJ degeneration. Indirect trauma plays a vital role in postfracture TMJ degeneration.

Risk factors associated with short-term complications in mandibular fractures: the MANTRA study-a Maxillofacial Trainee Research Collaborative (MTReC)

INTRODUCTION

Complications following mandibular fractures occur in 9-23% of patients. Identifying those at risk is key to prevention. Previous studies highlighted smoking, age and time from injury to presentation as risk factors but rarely recorded other possible confounders. In this paper, we use a collaborative snapshot audit to document novel risk factors and confirm established risks for complications following the treatment of mandibular fractures.

METHODS

The audit was carried out by 122 OMFS trainees across the UK and Ireland (49 centres) over 6 months, coordinated by the Maxillofacial Surgery Trainees Research Collaborative. Variables recorded included basic demography, medical and social history, injury mechanism and type, management and 30-day outcome.

RESULTS

Nine hundred and forty-seven (947) patients with fractured mandibles were recorded. Surgical management was carried out in 76.3%. Complications at 30 days occurred 65 (9%) of those who were managed surgically. Risk factors for complications included male sex, increasing age, any medical history, increasing number of cigarettes smoked per week, increasing alcohol use per week, worse oral hygiene and increased time from injury to presentation.

DISCUSSION

We have used a large prospective snapshot audit to confirm established risk factors and identify novel risk factors. We demonstrate that time from injury to presentation is confounded by other indicators of poor health behaviour. These results are important in designing trial protocols for management of mandibular fractures and in targeting health interventions to patients at highest risk of complications.

Isolated favorable compound mandibular body fractures: A retrospective review of two cohorts of patients based on the timing of treatment

BACKGROUND/AIM

Treatment delays in the management of mandible fractures are often unavoidable and, as a result, the timing of treatment of mandibular fractures has remained a contentious issue in clinical practice as the optimal treatment delay for minimizing complications remains unknown. The aim of this study was to determine the rate and types of complications between two cohorts of patients designated as early and late treatment groups and estimate an optimal time threshold for treatment delay after closed reduction and maxillomandibular fixation.

MATERIAL AND METHODS

Demographic and clinical data were collected retrospectively about patients who were treated for isolated, unilateral, favorable, and compound mandibular body fractures between 1999 and 2019 to answer the question of whether treatment delay is an independent variable impacting post-operative mandible body fracture complications. Descriptive and bivariate statistics were computed.

RESULTS

One hundred and seventy subjects were evaluated (n = 87 in the control/early group and n = 83 in the study/late group). The mean time lapses from injury to treatment were: early (5.8 ± 0.4 days) and late (10.3 ± 0.7 days). The overall complication rate was 14.1%. However, the complication rates of the early and late groups were 13.8% and 14.5%, respectively, with no significant difference (p = 0.89).

CONCLUSIONS

There was no difference between early and late treatment groups. Treatment delay was not an independent variable impacting post-operative mandible body fracture complications if treatment is done between 3 and 12 days after the injury.

Evaluation of Mandibular Fractures in a German Nationwide Trauma Center Between 2015 and 2017

Introduction

This study analyses the treatment of isolated mandibular fractures between 1.1.2015 and 21.31.2017 at Dortmund General Hospital.

Materials and Methods

Patient documentation and radiological images have been assessed, and a descriptive statistical analysis has been performed.

Results

Three hundred and twenty-eight patients were identified with isolated mandibular fractures (259 male, 69 female). The male-to-female ratio is 3.75: 1. A total of 541 fracture sites have been identified (1.65 fractures/patient). Forty of these were observed in the dentoalveolar region (fracture of the alveolar process, dental injuries), and the other 501 injuries were distributed in the remaining parts of the lower jaw.A detailed analysis of the osteosynthesis implants is provided. A total of 20 serious complications were observed (6% in all primary cases, 4.5% without osseointegrated implants).

Discussion

The demographic data and the anatomical distribution of the fracture sites are comparable with international literature. Dentoalveolar injuries mostly occur in younger patients. The complication rate in this study (4.5%) is below the international data; however, we found a considerably higher rate than in the midfacial region (central midface: 0%, lateral midface: 1.43%). Despite this complication rate, the procedure can be considered safe.

Supplementary information

The online version of this article (10.1007/s12663-021-01513-4).

Fracture Fixation Technique and Chewing Side Impact Jaw Mechanics in Mandible Fracture Repair

Lower jaw (mandible) fractures significantly impact patient health and well‐being due to pain and difficulty eating, but the best technique for repairing the most common subtype—angle fractures—and rehabilitating mastication is unknown. Our study is the first to use realistic in silico simulation of chewing to quantify the effects of Champy and biplanar techniques of angle fracture fixation. We show that more rigid, biplanar fixation results in lower strain magnitudes in the miniplates, the bone around the screws, and in the fracture zone, and that the mandibular strain regime approximates the unfractured condition. Importantly, the strain regime in the fracture zone is affected by chewing laterality, suggesting that both fixation type and the patient's post‐fixation masticatory pattern—ipsi‐ or contralateral to the fracture— impact the bone healing environment. Our study calls for further investigation of the impact of fixation technique on chewing behavior. Research that combines in vivo and in silico approaches can link jaw mechanics to bone healing and yield more definitive recommendations for fixation, hardware, and postoperative rehabilitation to improve outcomes. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Is Open Reduction Internal Fixation Using Titanium Plates in the Mandible as Successful as We Think?

ABSTRACT

Titanium plats are the gold-standard for fracture fixation. Titanium is considered biocompatible, corrosion resistant with an elasticity-modulus closest to bone. Nonetheless, titanium plates are not always as inherent as hoped. The authors investigated morbidity associated with titanium plates in mandibular fractures. A retrospective study of mandibular fractures treated between 2000 and 2018 using internal-fixation was conducted. Data included age, gender, complications, and location. Predictor-variable was location. Outcome-variable was plate removal. A total of 571 patients were included, 107 resulted in plate removal (18.7%). Body was the most prevalent location of fracture (29.3%). Symphysis/para-symphysis showed the highest removal rate (24.1%), followed by body and angle (21.3/19.8%). A total of 23.4% of double-plating cases resulted in plate removal, upper-border in 15% and lower-border in 8.8%, all reconstruction-plates. Exposure was the most frequent complication leading to removal. Although titanium plates are the gold standard, almost every fifth patient returns for plate removal. Age-distribution emphasizing 41 to 50 with decrease towards extremities may imply better healing in the young and soft-tissue elasticity and less complaints in the elderly. Significantly more complications in double-plating compared to lower border suggests proximity to the oral-cavity as a risk-factor for removal. Complication rates and patterns are not negligible and perhaps should encourage clinicians to consider using biodegradable-systems for upper-border plates.

A new classification of mandibular fractures

There is no accepted method of reporting mandibular fracture that reflects incidence, treatment and outcome for individual cases. As most series include anatomical site only for all fractures, the aim was to establish a new method to report fractures based on a systematic review of the literature and an internal audit. The classification proposed is: Class I; condyle, II; angle, IIc; II+condyle, III; body/symphysis, IIIc; III+condyle, IV; multiple fractures not including condyle, IVc; IV+condyle, V; bilateral condyle±other fracture(s). A total of 10,971 adult and 914 paediatric cases were analyzed through systematic review, and 833 from the regional audit. Only 32% (14/44) of reported series could be reclassified which, when added to the audit data, showed Class IV was most common (29%), with similar proportions of Class III, Class IIIc and Class II (18-23%). External validation (literature review) in terms of treatment and outcome was non-informative, but the internal validation (audit) demonstrated an increasing requirement for adding maxillomandibular fixation (MMF) to open reduction and internal fixation (ORIF) as class increased. The heterogeneity of data reporting found in the systematic review confirms the need for a classification such as this, likely to enhance comparison of varying management protocols.

Mandibular Fractures Epidemiology and Treatment Plans in the Center of Italy: A Retrospective Study

ABSTRACT

The epidemiology of maxillofacial fractures is variable in different geographic regions. Economic and social conditions, laws and types of behavior can be considered the most important factors influencing these differences.Mandibular fractures were first cited in 1650 BC in an Egyptian papyrus. Today, these fractures are one of the most prevalent facial skeletal injuries.A 4-year retrospective study was performed and the trauma - related data were collected from medical and radiological archives. The analysis comprised patients admitted for mandibular fracture at Sapienza University of Rome - Policlinico Umberto I between January 1, 2016 and December 31, 2019. The data include age, sex, etiology, anatomical sites of the fractures, eventual maxillofacial associated fractures and treatment.We collected 172 patients, 138 males (80.2%) and 34 females (19.8%) with 270 mandibular fractures. The average age was 35.4 years. The youngest and oldest patients were aged 6 and 90 years, respectively. The age group 20 to 29 years was the most represented with 52 patients (30.2% of the total sample). Assaults were the most common etiology (n = 53, 30.8%), followed by falls (n = 45, 26.2%). The condyle was the most involved region (n = 86, 32%), followed by parasymphysis region (n = 72, 26.6%) and angle (n = 62, 23%).154 patients (89.5%) reported only mandibular fractures. Eighteen patients (10.5%) had other associated maxillofacial fractures; the most frequently encountered maxillofacial fractures associated with mandibular fractures were the zygomatic complex fractures (n = 9, 5.2%). Open reduction and internal fixation was the most preferred surgical treatment (n = 115, 66.9%).This study showed that mandibular fractures predominate in 20 to 29 years group and in the male sex. Assaults are the most frequent cause. The prevalent fracturing site is condylar process. Orbital - maxillary - zygomatic complex fractures were the most common associated maxillofacial fractures and open reduction and internal fixation was the preferred surgical strategy.The results of this analysis agree to other studies and provide important clinical information that will help in study of these injuries.

Mandible Fractures Associated With the Introduction of an E-Scooter-Sharing System

ABSTRACT

With the introduction of an e-scooter-sharing system in Germany, standing electric scooters became popular modes of transportation in many urban areas. But the increase in popularity has resulted in an increase in traumatic injuries associated with e-scooter accidents. The purpose of this investigation was to determine the common fracture pattern of patients with mandible fractures as a result of an electric scooter accident. The authors performed a retrospective investigation of 52 patients who were admitted to the trauma unit of an oral and maxillofacial department from June until November 2019 with a fracture of the mandible. Our study investigated the first 6 months of e-scooter sharing system in a major city with more than 1 million inhabitants. Our cohort consists of 52 patients, 38 males, and 14 females with a mean age of 37 years. E-scooter related mandible fractures were with 21% the third biggest group, after physical assault and falls. 45% of these patients were intoxicated by alcohol. Furthermore, the majority of e-scooter patients presented more than one fracture of the mandible (73%). For our cohort, a typical combination of a symphysis or body fracture and bilateral affected ramus and/or condyle was the prevalent recorded fracture combination (55%) of e-scooter related traumata. Small scooter wheels, a speed of 15 miles or 20 kilometers per hour and the individual clinging to the handlebar falling predestinate these vehicles for accidents with craniofacial trauma. Among all cranio-facial traumas mandible fractures were mostly documented for e-scooter accidents. The severity of e-scooter related mandible fractures and their fracture pattern should be recognized by trauma units.

Trends in the incidence, prevalence and years lived with disability of facial fracture at global, regional and national levels from 1990 to 2017

Background

Facial fracture is one of the most common injuries globally. Some types of facial fractures may cause irreversible damage and can be life-threatening. This study aimed to investigate the health burden of facial fractures at the global, regional, and national levels from 1990 to 2017.

Methods

Facial fracture data, including the incidence, prevalence, and years lived with disability (YLDs) from 1990 to 2017, were obtained from the Global Burden of Disease study. We calculated the estimated annual percentage changes (EAPCs) to assess the changes of facial fractures in 195 countries or territories and 21 regions.

Results

From 1990 to 2017, the change in cases of facial fracture incidence was 39% globally, while the age-standardized incidence rate showed a downtrend with an EAPC of 0.00. Syria experienced a ten-fold increase in incidence cases with an EAPC of 9.2, and this condition is largely responsible for the global health burden of facial fractures. The prevalence and YLDs showed a similar trend worldwide as the incidence. Additionally, we found that the incidence, prevalence, and YLDs showed a discrepancy among various age groups with a gradual change of proportion over the past 28 years. The age-standardized rates (ASRs) of facial fractures were nearly twice for male than those for female from 1990 to 2017.

Conclusions

EAPC showed a correlation with the ASRs of facial fractures and had no relationship with socio-demographic index. The proportion of children and elderly suffering from facial fractures slightly changed with time. The ratio of facial fractures between males and females was 2:1. These findings suggest that more targeted and specific strategies based on age and gender should be established in various countries and regions.

A 6-Year Epidemiological Study of Mandibular Fractures in Traumatic Patients in North of Iran: Review of 463 Patients

BACKGROUND

Mandibular fracture is considered the second most common facial fracture worldwide. We aimed to evaluate the epidemiology of mandibular fractures in traumatic patients hospitalized at Velayat Teaching Hospital in Rasht, Iran for 6-year.

METHODS

In this retrospective study, all traumatic patients with mandibular fractures admitted to Velayat Teaching Hospital, Rasht, northern Iran for 6-year (2013-18) were enrolled. The data collection tool was a checklist consisting of two parts: demographic information, and injury data. All data were collected through the Hospital Information System (HIS), and analyzed using SPSS software and descriptive and analytical statistics tests.

RESULTS

Overall, 463 hospitalized patients were reviewed. Males had higher frequency than females. The most common accident place was rural roads. The most frequent mechanism of fractures was road accidents. The most common injuries occurred in motorcyclists, followed by car passengers, pedestrians, and cyclists. The highest and lowest frequency of injury occurred in September, and February, respectively. The most common site of fracture was condyle, followed by trunk. In concurrent fractures, the most frequently affected site was maxillary bone, followed by zygomatic bones, orbital, nasal, and frontal bones.

CONCLUSION

The majority of patients with mandibular fractures were young men of working age following motor vehicle accidents. Consequently, the most effective strategy for reducing accidents leading to mandibular fractures is considering all three components of human, environment, and vehicle.

Combination of Rigid and Nonrigid Fixation Versus Nonrigid Fixation for Bilateral Mandibular Fractures: A Multicenter Randomized Controlled Trial

PURPOSE

We aimed to compare complication rates and functional outcomes in patients with bilateral mandibular fractures treated with different degrees of internal fixation rigidity.

PATIENTS AND METHODS

This international, multicenter randomized controlled trial included adults with bilateral mandibular fractures located at either the angle and body, angle and symphysis, or body and symphysis. Patients were treated with either a combination of rigid fixation for the anterior fracture and nonrigid fixation for the posterior fracture (mixed fixation) or nonrigid fixation for both fractures. The primary outcome was complications within 6 weeks after surgery. Secondary outcomes were complications within 3 months, Helkimo dysfunction index, and mandibular mobility at 6 weeks and 3 months after surgery.

RESULTS

Of the 315 patients enrolled, 158 were randomized to the mixed fixation group and 157 to the nonrigid fixation group. The overall complication rate at 6 weeks in the intention-to-treat population was 9.6% (95% confidence interval [CI], 5.3% to 15.6%) in the mixed fixation group and 7.8% (95% CI, 4.0% to 13.5%) in the nonrigid fixation group. With an unadjusted odds ratio of 1.25 (95% CI, 0.51 to 3.17), there were no statistically significant differences in complication rates between the 2 groups (P = .591). A multivariable model for complication risk at 6 weeks found no significant differences between treatment groups, but patients with moderate or severe displacement had a higher complication rate than those with no or minimal displacement (adjusted odds ratio, 4.58; 95% CI, 1.16 to 18.06; P = .030). There were no significant between-group differences in complication rates at 3 months. Moreover, no significant differences in Helkimo dysfunction index and mandibular mobility index at 6 weeks and 3 months were found between groups according to treatment allocated and treatment received.

CONCLUSIONS

A combination of rigid and nonrigid fixation in patients with bilateral mandibular fracture has similar complication rates and functional outcomes to nonrigid fixation for both fractures.

Impact Protection Potential of Mammalian Hair: Testing the Pugilism Hypothesis for the Evolution of Human Facial Hair

Because facial hair is one of the most sexually dimorphic features of humans (Homo sapiens) and is often perceived as an indicator of masculinity and social dominance, human facial hair has been suggested to play a role in male contest competition. Some authors have proposed that the beard may function similar to the long hair of a lion’s mane, serving to protect vital areas like the throat and jaw from lethal attacks. This is consistent with the observation that the mandible, which is superficially covered by the beard, is one of the most commonly fractured facial bones in interpersonal violence. We hypothesized that beards protect the skin and bones of the face when human males fight by absorbing and dispersing the energy of a blunt impact. We tested this hypothesis by measuring impact force and energy absorbed by a fiber epoxy composite, which served as a bone analog, when it was covered with skin that had thick hair (referred to here as “furred”) versus skin with no hair (referred to here as “sheared” and “plucked”). We covered the epoxy composite with segments of skin dissected from domestic sheep (Ovis aries), and used a drop weight impact tester affixed with a load cell to collect force versus time data. Tissue samples were prepared in three conditions: furred (n = 20), plucked (n = 20), and sheared (n = 20). We found that fully furred samples were capable of absorbing more energy than plucked and sheared samples. For example, peak force was 16% greater and total energy absorbed was 37% greater in the furred compared to the plucked samples. These differences were due in part to a longer time frame of force delivery in the furred samples. These data support the hypothesis that human beards protect vulnerable regions of the facial skeleton from damaging strikes.

Risk Factors Associated With Complications After Treatment of Mandible Fractures

Importance

Complications that arise after treatment of mandible fractures can result in significant morbidity. Identifying modifiable risk factors associated with these complications is valuable in guiding clinical practice for improved patient outcomes.

Objective

To describe the risk factors associated with complications in patients undergoing treatment for mandible fracture.

Design, Setting, and Participants

A retrospective review was conducted of 137 patients presenting to a tertiary care, level 1 trauma center with mandible fractures between January 1, 2014, and January 1, 2017. Outcomes and demographic characteristics for patients with at least 3 weeks of follow-up were compared using multivariate logistic regression analysis.

Results

Of the 137 patients meeting inclusion criteria, there were 113 males (82.5%) and 24 females (17.5%), with a mean (SD) age at presentation of 32.3 (15.7) years. Median follow-up was 71 days (range, 22-1189 days). Postoperative complications were identified in 29 patients (21.2%); complications included wound dehiscence or surgical site infection (n = 17), bony nonunion (n = 5), and hardware exposure (n = 13). Complications were managed surgically in 19 patients and nonsurgically in 10 patients. On univariate analysis, the initial surgery was completed later (mean [SD], 5.9 [6.6] days after injury) in patients who developed complications than in those who did not (mean [SD], 3.8 [4.0] days). On multivariate analysis, complications were associated with increased time from injury to treatment (odds ratio [OR], 1.60; 95% CI, 1.02-2.53; P = .04), tobacco use (OR, 8.10; 95% CI, 1.26-52.00; P = .03), and dental extraction (OR, 93.00; 95% CI, 1.19 to >999.00; P = .04). Residence in the same city as the medical center was associated with fewer complications (OR, 0.08; 95% CI, 0.01-0.69; P = .02).

Conclusions and Relevance

In a 3-year review of mandible fractures managed at a single academic center, complications were associated with an increased time to treatment, tobacco use, dental extraction, and living farther from the treatment facility. On a systems level, the results of this study suggest that expediting intervention for mandible fractures may improve outcomes.

Level of Evidence

3.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I-Mandibular Fractures

PURPOSE

The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

MATERIALS AND METHODS

The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and χ² analyses were performed to compare complication rates between groups.

RESULTS

The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis.

CONCLUSIONS

Our results do not support the idea of a "July effect" regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty.

Pattern of maxillofacial injuries in patients with craniocerebral injuries: a prospective study

Introduction: This prospective study highlights the pattern of oral and maxillofacial injuries in patients with associated craniocerebral injuries. Material and Methods: This was a prospective descriptive study conducted over a 22-month period. Information was collected using a structured questionnaire and analyzed using Statistical Package for Social Sciences (SPSS) Version 13 (SPSS Inc., Chicago, IL, USA) and Microsoft Office Excel 2007 (Microsoft, Redmond, WA, USA). Test of statistical significance was set at 0.05. Results: Three hundred and three consecutive patients were studied and this consisted of 254 males and 49 females. The difference in the gender distribution was statistically significant (p = 0.008). Road traffic crashes (n = 262; 86.5%) was the most common cause of injury and soft tissues orofacial injuries accounted for 61.7% of injuries. Le Fort II fractures were the major skeletal injuries. Glasgow Coma Score (GCS) of 13–15 had the highest frequency (n = 157; 53.4%). Intracerebral haemorrhage was the most common cerebral injury recorded and the commonest complication noted was dysocclusion. Discussion: Although middle third facial fractures were the most common skeletal injury, fractures of the upper third facial skeleton appear to be associated with lower GCS. Conclusion: Fractures of the facial skeleton are fairly common in craniocerebral injuries.

Rare Mandibular Ramus Fracture

Mandibular fractures represent approximately two-thirds of all maxillofacial fractures (nearly 70%), out of which fractures of mandibular ramus represent 3.09% which is considered to be a rare fracture site. They occur alone or in combination with other facial bone fractures resulting in loss of function and disfigurement. The pattern of mandibular fractures varies with geographic location, physical activity, social, cultural, and environmental factors. The main causes of mandibular fracture are road traffic accidents, interpersonal violence, falls, sports injuries, industrial trauma, and pathological fractures. In this clinical case, the authors describe a vertical ramal fracture extending from subsigmoid region to inferior border of angle of the mandible combined with symphysis fracture which was surgically operated through open reduction and internal fixation by extraoral approach.

Mandibular Fracture Patterns at a Medical Center in Central Taiwan: A 3-Year Epidemiological Review

Mandibular fractures constitute a major portion of maxillofacial trauma and may lead to considerable functional and aesthetic sequelae if treatment is inadequate or delayed. An epidemiology study on mandibular fractures may guide the preventive efforts of the Taiwan public health care system. Therefore, a retrospective review was conducted at a medical center in central Taiwan to evaluate the current mandibular fracture epidemiology.The medical records and digitized radiographs of 198 patients who received treatment for mandibular fractures during a 3-year period (from October 2010 to September 2013) at a medical center in central Taiwan were reviewed to obtain demographic and injury data.The average age was 29.4 years (3-82 years). Patients aged 21 to 30 years sustained the most mandibular fractures (62 patients, 31.3%). The overall sex distribution (male to female) ratio was 1.8. Motor-vehicle accidents (MVAs) were the most common mechanism of injury (162 patients, 82%), and scooter and motorcycle riders wearing partial-coverage helmets constituted the majority of patients. A chart review identified 198 patients with 335 mandibular fractures; 113 patients (57.1%) had multiple mandibular fractures. The most common fracture sites were the symphysis and parasymphysis regions (38.9%), followed by the condyle (26.0%), angle (14.3%), body (14.3%), and ramus (6.6%).MVAs are the major cause of mandibular fractures in central Taiwan, and patients aged <30 years sustained the most mandibular fractures. Compared with previous studies, the present study has a higher percentage of women with mandibular fractures. In addition, inadequate mandibular protection by partial-coverage helmets may be a major reason for mandibular fractures most commonly localized in the symphysis and parasymphysis regions. The incidence and causes of mandibular fractures may reflect the trauma patterns within the community, thus facilitating the development of a preventive strategy for the socioeconomic and environmental background of central Taiwan.

The epidemiology of mandibular fractures in Caracas, Venezuela: Incidence and its combination patterns

BACKGROUND/AIM

As reported in the literature by several authors, there is a great variation between countries in terms of etiology and patterns of mandibular fractures. The aim of this study was to determine the incidence of mandibular fractures at the Oral and Maxillofacial Surgery Unit, "Dr. Domingo Luciani" Hospital, Venezuela, during the period January 2010 to March 2013.

MATERIALS AND METHODS

A retrospective study was conducted to assess the etiology of trauma, age group, gender, anatomic distribution of injury, and combination patterns by reviewing patients records.

RESULTS

There were 334 patients with 522 mandibular fractures averaging 1.56 fractures per patient. Eighty-five percent of the patients were males with an overall male: female ratio of 6.15:1. The highest occurrence of trauma was in the 20-29 years (43.4%) age group. The etiology most frequently observed was motorcycle traffic accidents in 94 patients (28.1%), and the parasymphysis region was the most common location with 144 (27.6%) fractures. Almost half (48.8%) of the injuries were combined mandibular fractures with 29 different combinations, and the most common was a mandibular body fracture + parasymphysis fracture (22.1%).

CONCLUSION

Mandibular fracture is a common facial injury with variable incidence and etiology across gender and age range. The findings of this study are similar to other studies and provide important clinical information that will assist in the treatment planning of these types of injuries.

Patterns Associated with Adult Mandibular Fractures in Southern Taiwan-A Cross-Sectional Retrospective Study

Purpose: This study aimed to determine the patterns associated with adult mandibular fractures from a Level-I trauma center in southern Taiwan. Methods: The data of adult trauma patients admitted between 1 January 2009 and 31 December 2014 were retrieved from the Trauma Registry System and retrospectively reviewed. Fracture site and cause of injury were categorized into groups for comparison, and corresponding odds ratios (ORs) and 95% confidence intervals (CIs) were obtained by multivariate logistic regression. Results: Motorcycle accidents were the most common cause of mandibular fractures (76.3%), followed by falls (10.9%), motor vehicle accidents (4.8%), and being struck by/against objects (4.5%). Of the 503 cases of mandibular fractures, the condylar neck and head were the most common sites (32.0%), followed by the parasymphysis (21.7%), symphysis (19.5%), angle and ramus (17.5%), and body (9.3%). The location of mandibular fractures in patients who had motorcycle accidents was similar to that in all patients. Motor vehicle accidents resulted in a significantly higher number of body fractures (OR 3.3, 95% CI 1.24-8.76, p = 0.017) and struck injury in a significantly higher number of angle and ramus fractures (OR 3.9, 95% CI 1.48-10.26, p = 0.006) compared to motorcycle accidents. The helmet-wearing status and body weight were not associated with the location of mandibular fractures in motorcycle accidents. Conclusions: Our study revealed that the anatomic fracture sites of mandible were specifically related to different etiologies. In southern Taiwan, motorcycle accidents accounted for the major cause of mandibular fractures and were associated with the condylar neck and head as the most frequent fracture sites. In contrast, motor vehicle accidents and struck injuries tended to cause more body fracture as well as angle and ramus fracture compared to motorcycle accidents. Furthermore, the status of helmet-wearing and body weight were not associated with the location of mandible fractures caused by motorcycle accidents.

Impact of Injury Mechanisms on Patterns and Management of Facial Fractures

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Epidemiology and resource utilization in pediatric facial fractures

BACKGROUND

Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures.

METHODS

Using the 2000-2009 Kids' Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes.

RESULTS

Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges.

CONCLUSIONS

There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.

Mandibular Ramus Fracture: An Overview of Rare Anatomical Subsite

Aim. The present study aims at exemplifying the incidence, and aetiology and analyses the outcomes of open reduction internal fixation (ORIF) over closed treatment of mandibular ramus fractures. Patients and Method. In the present retrospective analysis of mandibular fracture patients, variables analysed were age, sex, cause of injury, pretreatment occlusion, treatment given, period of maxillo-mandibular fixation (MMF), and posttreatment occlusion. Results. Out of 388 mandibular fractures treated, ramus fractures were 12 (3.09%). In the present study, predominant cause of mandibular ramus fracture was road traffic accident (RTA) n = 07 (58.33%) followed by fall n = 04 (33.33%) and assault n = 1 (8.33%). The average age was 35.9 years with a male predilection. Of these, 9 patients were treated with ORIF while remaining 3 with closed treatment. The average MMF after closed treatment was 21 days and 3 to 5 days after ORIF. There was improvement in occlusion in all 12 patients posttreatment with no major complication except for reduced mouth opening in cases treated with ORIF which recovered with physiotherapy and muscle relaxants. Conclusion. Mandibular ramus fractures accounted for 3.09% with RTA as a common aetiology. ORIF of ramus fractures facilitated adequate functional and anatomic reduction with early return of function.

Clinical Features and Treatment Modes of Mandibular Fracture at the Department of Oral and Maxillofacial Surgery, Shimane University Hospital, Japan

Background

The number of elderly patients with maxillofacial trauma is rapidly increasing due to active lifestyles and longevity. Shimane prefecture has the fastest growing proportion of elderly individuals in Japan. The aim of this study was to reveal the distinctive features and treatment modes of mandibular fracture treatment mode in patients requiring hospitalization at the Department of Oral and Maxillofacial Surgery, Shimane University Hospital, Japan.

Patients and Methods

Patient age, sex, period between injury and first consultation, years since injury, cause of injury, fracture site, treatment, and duration of hospitalization were evaluated. Univariate Poisson regression, relative risk with 95% confidence interval based on the Wald test, Fisher’s exact test, and Kruskal-Wallis test were used to explore associations among clinical and demographic variables.

Results

In total, 305 patients were diagnosed with and hospitalized for mandibular fracture from 1980 to 2010. Younger age increased the risk for mandibular fracture. Incidence was higher in males than females, particularly in the young, but the male to female ratio decreased with age. The period until first hospital consultation decreased progressively over the study period. Fall was a much more frequent cause in patients aged ≥60 than in those aged <60 years. Mandibular fracture with condyle, symphysis, and angle involvement were most common and were associated with sex, age, and treatment mode. Length of hospitalization has decreased since 1980.

Conclusion

In our department, patients aged ≥60 years accounted for a greater proportion of mandibular fracture cases than in many previous studies, reflecting the greater proportion of elderly residents in Shimane prefecture.

Incidence and pattern of mandibular fractures in Rohilkhand region, Uttar Pradesh state, India: A retrospective study

AIMS

To understand and evaluate the significance of various aetiological factors in determining the incidence and dictating the patterns of mandibular fractures in Rohilkhand region.

METHODS

The patient records and radiographs for 144 patients treated for mandibular fractures were reviewed between the time periods from January 2012 to December 2013. Data on age, gender, aetiology, use of intoxicants, head injury, associated injuries, days of the week, anatomic site and multiple fractures within the mandible were recorded and assessed.

RESULTS

Maximum incidence of fractures was observed among the individuals in 3rd decade (35.4%) followed by 2nd and 4th decades, which exhibited 32 and 30 cases (22.2% and 20.8%), respectively. Male to female ratio was biased (4:1) portraying a male predominance. Road traffic accidents (RTAs) were observed to be the predominant aetiological factor responsible accounting for 79.2% of the total injuries followed by assaults (11.8%) and falls (9%). Parasymphysis exhibited the highest incidence (32.63%) amongst the anatomic sites, followed by body (18.75%), angle (16.66%), condyle (15.27%), symphysis (12.50%), ramus (2.77%) and coronoid (1.38%).

CONCLUSION

The study reveals that majority of affected patients were in the 2nd and 3rd decades. A definitive relationship existed between RTA and the incidence of mandibular fractures. The frequency further increased with consumption of social intoxicants. The most commonly fractured site was parasymphysis either isolated or associated with other fractures in the mandible.

Mandibular trauma: a two-centre study

The aims of this study were to assess and compare epidemiological data on mandibular fractures from two European centres and to perform a review of the literature. Between 2001 and 2010, a total of 752 patients with a total of 1167 mandibular fractures were admitted to a hospital in Turin, and 245 patients with a total of 434 mandibular fractures were admitted to a hospital in Amsterdam. The mean age in Turin was 34.8 years and in Amsterdam was 32 years. The age group 20-29 years showed the highest incidence of mandibular fractures in both centres. The fractures were mainly the result of assaults, in agreement with several articles in the recent literature, followed by falls. The continuous long-term and multicentre collection of data on the epidemiology of maxillofacial trauma is important because it provides the information necessary for the development of preventative measures aimed at reducing the incidence of facial injuries.

Mandibular trauma treatment: a comparison of two protocols

Objectives: The aim of this study was to evaluate the treatment of mandibular fractures treated in two European centre in 10 years. Study Design: This study is based on 2 systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures in two centers in Turin, Italy and in Amsterdam, the Netherlands for ten years. Only patients who were admitted for mandibular fractures were considered for this study. Results: Between 2001 and 2010, a total of 752 patients were admitted at Turin hospital with a total of 1167 mandibular fractures not associated with further maxillofacial fractures, whereas 245 patients were admitted at Amsterdam hospital with a total of 434 mandibular fractures. At Amsterdam center, a total of 457 plates (1.5 - 2.7 mm) were used for the 434 mandibular fracture lines, whereas at Turin center 1232 plates (1.5 – 2.5 mm) were used for the management of the 1167 mandibular fracture lines. At Turin center, 190 patients were treated primarily with IMF, whereas 35 patients were treated with such treatment option at Amsterdam center. Conclusions: Current protocols for the management of mandibular fractures are quite efficient. It is difficult to obtain a uniform protocol, because of the difference of course of each occurring fracture and because of surgeons’ experiences and preferences. Several techniques can still be used for each peculiar fracture of the mandible.

Key words:Mandibular fracture, facial trauma, maxillofacial, treatment, multicentre, database.

Evidence-based medicine: Mandible fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the anatomy and subunits of the mandible. 2. Review the cause and epidemiology of mandible fractures. 3. Discuss the preoperative evaluation and diagnostic imaging. 4. Understand the principles and techniques of mandible fracture reduction and fixation.

SUMMARY

The management of mandibular fractures has undergone significant improvement because of advancements in plating technology, imaging, and instrumentation. As the techniques in management continue to evolve, it is imperative for the practicing physician to remain up-to-date with the growing body of scientific literature. The objective of this Maintenance of Certification article is to present a review of the literature so that the physician may make treatment recommendation based on the best evidence available. Pediatric fractures have been excluded from this article.

The Cost and Inpatient Burden of Treating Mandible Fractures

Objective

To discuss patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures.

Study Design

Cross-sectional study.

Setting

The 2009 Nationwide Inpatient Sample (NIS) database.

Subjects/Methods

Patient demographics, hospital characteristics, fracture locations, and common comorbidities for patients with isolated mandible fractures were analyzed, and variables associated with increased cost and length of hospitalization stay were ascertained.

Results

A total of 1481 patients were identified with isolated mandible fractures. The average age was 32, 85.4% were male, 39% were Caucasian, and 25% African American. Forty percent were from the lowest median household income quartile, and 77% were uninsured or government funded. The average length of stay (LOS) was 2.65 days, and average hospitalization cost was $35,804. A statistically significant increased LOS was associated with alcohol abuse, drug abuse, mental illness, diabetes mellitus type 2, cardiovascular disease, HIV, and age over 40. There was a statistically significant increased total cost associated with drug abuse, alcohol abuse, mental illness, cardiovascular disease, and age over 40.

Conclusion

The average cost for treatment of mandible fractures was $35,804 per person with increased expenditures for older patients and those with a history of mental illness, cardiovascular disease, or substance abuse. To improve outcomes and reduce hospital charges, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.

Protective buttressing of the hominin face

When humans fight hand-to-hand the face is usually the primary target and the bones that suffer the highest rates of fracture are the parts of the skull that exhibit the greatest increase in robusticity during the evolution of basal hominins. These bones are also the most sexually dimorphic parts of the skull in both australopiths and humans. In this review, we suggest that many of the facial features that characterize early hominins evolved to protect the face from injury during fighting with fists. Specifically, the trend towards a more orthognathic face; the bunodont form and expansion of the postcanine teeth; the increased robusticity of the orbit; the increased robusticity of the masticatory system, including the mandibular corpus and condyle, zygoma, and anterior pillars of the maxilla; and the enlarged jaw adductor musculature are traits that may represent protective buttressing of the face. If the protective buttressing hypothesis is correct, the primary differences in the face of robust versus gracile australopiths may be more a function of differences in mating system than differences in diet as is generally assumed. In this scenario, the evolution of reduced facial robusticity in Homo is associated with the evolution of reduced strength of the upper body and, therefore, with reduced striking power. The protective buttressing hypothesis provides a functional explanation for the puzzling observation that although humans do not fight by biting our species exhibits pronounced sexual dimorphism in the strength and power of the jaw and neck musculature. The protective buttressing hypothesis is also consistent with observations that modern humans can accurately assess a male's strength and fighting ability from facial shape and voice quality.

Prevalence of mandibular fractures reported at C.S.M.S.S Dental College, aurangabad from february 2008 to september 2009

Aim:

The aim of this study is to determine the etiology, frequency of mandibular fractures among different age and sex, to determine the frequency of anatomic distribution, and to report the different modalities of treatment provided to the patients reported at our institution from February 2008 to September 2009.

Materials and Methods:

All patients fulfilling the selection criteria and having mandible fracture were selected for the study. Patient information was collected by means of a medical data form specifically designed for the present study. The values were subjected to Z and Chi-square tests.

Results:

Out of 35 patients, thirty one were males (88.57%) and four were females (11.43%) with a male:female ratio of 8:1. We found a peak occurrence in young adults, aged 21-30 years (n = 15, 42.86%). In case of etiology of fracture, road traffic accidents (RTAs) was the most common (n = 25, 71.43%) and condyle was most frequently involved site (n = 19, 38.78%). In most (n = 16, 45.71%) of the patients, an open reduction and rigid internal fixation using bone plate and screws was done.

Conclusion:

In the present study, the prevalence of mandible fractures was more prevalent in male patients, especially during the 3^rd decade of life. The most common cause was road traffic accident and the more frequently affected region was condyle of the mandible. Open reduction and rigid internal fixation using miniplates and screws was the most commonly used treatment.

Mandibular Angle Fractures: Comparison of One Miniplate vs. Two Miniplates

BACKGROUND

Monocortical miniplate fixation is an accepted and reliable method for internal fixation of mandibular angle fractures. Although placement of a second miniplate may theoretically provide more stability; however, the clinical importance of this issue remains controversial.

OBJECTIVES

The present study assessed the postoperative complications and outcomes associated with the fixation of mandibular angle fractures using 1 and 2 miniplates in patients with favorable mandibular angle fractures.

PATIENTS AND METHODS

A prospective study of 87 patients (73 males, 14 females) with favorable mandibular angle fractures was done. In the first group, a 4-hole miniplate was placed at the superior border through an intraoral approach. In group 2, patients were treated with 2 miniplates, one placed at the superior border (similar to group 1) and the other on the lateral aspect of the angle at the inferior border through an intraoral and transcutaneous approach using a trocar. Postoperative complications including malocclusion, malunion and sensory disturbances associated with surgery, additional maxillomandibular fixation (MMF) by means of an arch bar and wires for a longer period (for delayed union) and infection were assessed in patients of both groups up to 12 months postoperatively. The data were analyzed using the chi-square test.

RESULTS

In the single miniplate group, 25 patients showed lip numbness associated with surgery (55.6%), 22 patients required additional use of MMF (48.9%) and 3 patients developed infections (6.7%). In the double miniplate group 20 patients showed lip numbness associated with surgery (47.6%), 18 patients required additional use of MMF (42.9%) and 1 patient developed infection (2.4%). None of the patients in either group showed malocclusion or malunion. No significant difference was observed between the groups regarding overall complication rate.

CONCLUSIONS

In this study, use of one miniplate or two miniplates for treatment of favorable mandibular angle fractures was associated with a similar incidence of complications. Thus, it seems that the use of two miniplates in this setting may not be warranted, nor cost-efficient.