Incidence and patterns of maxillofacial trauma-a retrospective analysis of 3611 patients-an update

BACKGROUND

Maxillofacial fractures occur in a significant proportion worldwide and can occur as an isolated injury or in combination with other severe injuries including cranial, spinal, and upper and lower body injuries requiring prompt diagnosis with possible emergency interventions. The epidemiology of facial fractures varies with regard to injury type, severity, and cause and depends on the population studied. Hence, understanding of these factors can aid in establishing clinical and research priorities for effective treatment and prevention of these injuries.

MATERIALS AND METHODS

In this present retrospective study, we provide a comprehensive overview regarding cranio-maxillofacial trauma on 3611 patients to assist the clinician in assessment and management of this unique highly specialized area of traumatology. A preformed pro forma was used to analyze the medical records of patients treated for facial trauma in The Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai. The distribution according to age, gender, etiology, type of injury, time interval between accident and treatment, loss of consciousness, facial bones involved, pattern of fracture lines, treatment offered, and postoperative complications were recorded and evaluated.

RESULTS

We inferred male patients sustained more injuries mostly in the third decade of age. Road traffic accidents were the most common cause of injury. Mandible was the most commonly fractured bone in the facial skeleton. Soft tissue injuries occurred more in road traffic accidents and upper lip was the commonest site of injury.

CONCLUSION

Our study provides insights into the epidemiology of facial injuries and associated factors and can be useful not only in developing prevention strategies but also for grading the existing legal regulations and also for framing a more effective treatment protocol.

Bad splits in bilateral sagittal split osteotomy: systematic review of fracture patterns

An unfavourable and unanticipated pattern of the mandibular sagittal split osteotomy is generally referred to as a 'bad split'. Few restorative techniques to manage the situation have been described. In this article, a classification of reported bad split pattern types is proposed and appropriate salvage procedures to manage the different types of undesired fracture are presented. A systematic review was undertaken, yielding a total of 33 studies published between 1971 and 2015. These reported a total of 458 cases of bad splits among 19,527 sagittal ramus osteotomies in 10,271 patients. The total reported incidence of bad split was 2.3% of sagittal splits. The most frequently encountered were buccal plate fractures of the proximal segment (types 1A-F) and lingual fractures of the distal segment (types 2A and 2B). Coronoid fractures (type 3) and condylar neck fractures (type 4) have seldom been reported. The various types of bad split may require different salvage approaches.

Magnetic Resonance Evidence of Joint Effusion of the Temporomandibular Joint After Fractures of the Mandibular Condyle: A Preliminary Report

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p < 0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p < 0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.

Mandibular fracture scoring system: for prediction of complications

INTRODUCTION

Mandibular fractures are one of the most commonly encountered injuries in trauma clinics. Although several widely accepted classification systems exist, these are mostly region specific, differ in the classification criteria used, and are sometimes only correlated with specific treatment modalities, thereby making it impossible to uniformly and comprehensively document facial fracture patterns. In this study, we developed a modified scoring system for mandibular fractures and analyzed the relationship between scoring of fractures that were treated and the incidence of complications after surgical treatment.

MATERIALS AND METHODS

To evaluate the suitability of the proposed scoring system, a prospective study on a series of 116 patients was performed. All the fractures were classified using the proposed scoring system. The scoring was based on clinical and radiological evaluation of each fracture. Patients were followed up postoperatively for presence of complications.

RESULTS

A good correlation between the proposed scoring system and the incidence of complications was detected.

DISCUSSION

This scoring system for mandibular fractures facilitates an objective and standardized assessment of the degree of severity of a fracture, thereby allowing for systematic evaluation of facial fracture outcomes, including assessment of complications. However, it is our understanding that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.

Manual reduction of mandibular fractures before internal fixation leads to shorter operative duration and equivalent outcomes when compared with reduction with intermaxillary fixation

PURPOSE

Open reduction of mandibular fractures before internal fixation is most commonly performed by 1 of 2 methods: intermaxillary fixation (IMF) or manual reduction. There are risks to both patient and clinician associated with using IMF. Furthermore, previous retrospective studies have failed to show any advantage in its use. The purpose of this study was to directly compare the use of manual reduction (experimental group) and IMF (control group) in open reduction-internal fixation of mandibular fractures.

MATERIALS AND METHODS

Patients who presented with isolated mandibular fractures at 2 hospitals in Queensland, Australia, from May 2009 to June 2010 were enrolled in a prospective controlled trial comparing IMF and manual reduction. The outcome measures were operative duration (primary outcome), as well as radiographic outcome, occlusal outcome, and complications (secondary outcomes). The patient and assessor were blinded to the type of reduction used before fixation. The study hypothesis is that manual reduction allows internal fixation in a shorter time than IMF with an equivalent outcome.

RESULTS

We recruited 50 patients, 26 allocated to IMF and 24 allocated to manual reduction before internal fixation of mandibular fractures. IMF was associated with an increased duration of procedure (P < .001) and increased complication rate (P = .063), without any observable benefit with regard to either radiographic outcome or occlusal outcome.

CONCLUSIONS

IMF is not required in open reduction-internal fixation of mandibular fractures that met our inclusion criteria. IMF is associated with increased costs to the health service and risks to both the patient and clinician.

Comparison of 3-dimensional and standard miniplate fixation in the management of mandibular fractures

PURPOSE

The aim of this follow-up study was to compare 3-dimensional (3D) and standard (Champy's) miniplate fixation in the management of mandibular fractures, and to analyze advantages and disadvantages of one over the other.

PATIENTS AND METHODS

A prospective randomized clinical trial was carried out in patients with well-defined inclusion and exclusion criteria. Patients were followed for 2 months for wound dehiscence, infection, segmental mobility, postoperative occlusion, significant period of postoperative complications, and radiological evaluation of reduction and fixation.

RESULTS

Twenty patients were enrolled in both the groups with no case of wound dehiscence. In group 1, 2 patients had mild segmental mobility (P = .07), 2 patients had surgical site infection (P = .07), and 2 patients involving mental nerve had involved roots of teeth (P = .07). Radiological evaluation did not show any statistically significant difference in reduction (P = 1.4), but showed a significant difference (P = .03) in fixation between the 2 groups, especially in cases involving the mental nerve (ie, fracture near or involving the mental foramen) and oblique fractures.

CONCLUSION

Champy's miniplate system is a better and easier method than the 3D miniplate system for fixation of mandibular fractures. In comparison, the 3D miniplate system is unfavorable for use in cases of oblique fractures and those involving the mental nerve, and is also difficult to adapt. In most cases, it provides good stability but with excessive implant material because of extra vertical bars incorporated for countering the torque forces. However, operative time is less because of simultaneous stabilization at both superior and inferior borders.

[An investigation of current consensus on the management of condylar fractures among Chinese senior maxillofacial surgeons]

OBJECTIVE

To determine the current consensus in the management of condylar fractures among Chinese senior oral and maxillofacial (OM) surgeons and the difference between domestic and international.

METHODS

Forty-six senior OM surgeons, who were considered to be expert in management of maxillofacial trauma, were invited to participate in this investigation. A questionnaire was designed to appraise management strategies of surgical and non-surgical treatment on the 18 fractures of condylar process of mandible, which varied in fracture patterns, the degree of fragment displacement, uni-and bi-lateral involved and the age range of patients. The consensus was analyzed and then compared with the current international practice based on Baker's survey.

RESULTS

Three fracture situations obtained a uniform opinion, 9 situations had tendency in the alternative of surgical and non-surgical approach, 6 situations had no preference. Of 18 fractures, 8 were advised to receive an open procedure in management of the condylar fracture compared with 4 which was considered to be in a close procedure. Others were obscure in the preference of treatment decision. Consensus was achieved in non-surgical treatment for the patients younger than 12 years in age, and the teenager patients were considered for an open treatment when fracture occurred at the base of condyle and the fragment located out of fossa. It was controversial over the treatment of sagittal or comminuted fracture and subcondylar fracture with slight displacement in the adults. The panel of surgeons admitted a practice that bilateral subcondylar dislocated fractures were indicated for open reduction and internal fixation. If the similar case occurred on the unilateral joint, most of the Chinese surgeon preferred a surgical intervention which was adverse opinion from international.

CONCLUSIONS

In regard to the decision of surgical and non-surgical treatment for condylar fracture of the mandible, much controversy remained in one third of the investigated cases. The shared opinion was that the children patients should be treated by the closed methods for the condylar fracture and the bilateral subcondylar dislocated fractures were identically indicated for surgical reduction. The domestic OM surgeons seem to have a more tendency to surgery compared with their international counterparts.

[A comparative study of two imaging techniques for the diagnosis of sagittal fracture of mandible condyle]

OBJECTIVE

To investigate the relationship between fractured fragment and joint disc displacement after sagittal fracture of mandibular condyle (SFMC).

METHODS

based on CT examination, SFMC were classified into fissue, displacement and dislocation type. Based on oblique sagittal MRI examination, the displacement of joint disc was grouped into type A and type B. Abnormal superiorposterior attachment was classified into elongation and avulsion type.

RESULTS

CT exmination were taken in 26 patients with 41 SFMC. There were 5 SFMC (12%) with fissue type, 18 SFMC (44%) with displacement type and 18 SFMC (44%) with dislocation type. Both CT and MRI examination were taken in 19 patients with 32 SFMC. There were 27 (84%) SFMC with disc displacement. Five SFMC with type fissue showed no signs of disc displacement. Among 15 SFMC with type displacement, there were 3 cases with type A disc displacement and 12 cases with type B disc displacement. All the dislocated SFMC (12 cases) were type B disc displacement. In term of superiorposterior attachment figures, 4 cases (4/5) of type fissue SFMC showed normal. 14 cases (14/15) of the displacement SFMC showed elongated and all cases with dislocated SFMC showed sign of avulsion. There were 20 cases (63%) showing superior joint effusion. There were 13 cases (13/15) with displaced SFMC and 6 cases with dislocated SFMC showing joint effusion. One case with fissue SFMC showed no sign of joint effusion.

CONCLUSIONS

Joint effusion, disc displacement and abnormal superiorposterior attachment were related to the displacement of condyle which was involved with SFMC.

Closed reduction of the mandibular fracture

The search for the ideal method of treatment for mandibular fractures has continued for thousands of years. These injuries have unique and problematic features for adequate reliable wound healing. Oral and maxillofacial surgeons must learn and master several techniques for mandibular fracture treatment. The age-old successful management of these injuries using closed reduction techniques always should be considered when mandibular trauma presents. The closed reduction remains a mainstay of mandibular fracture treatment. An adequate knowledge of anatomy, multiple closed reduction techniques, and the physiology of fracture healing must be adequately understood and technically mastered by the oral and maxillofacial surgical team for the present and future of mandibular fracture management.

Management of condylar fractures

Management of condylar fractures remains a source of ongoing controversy. While it appears that many condylar fractures can be managed nonsurgically, recognition of cases that require surgical intervention and selection of an appropriate procedure are paramount to success in treating these injuries. There are a variety of special considerations that are peculiar to the condylar region. This article discusses anatomic considerations, classification of condylar fractures, indications for surgery, treatment options, and complications. The goals of treatment include restoration of function and esthetics. Careful consideration and attention to the principles of fracture management, and the role of the condyle as an articulating unit and growth center, must be taken into account for the successful management of these injuries.

Prospective closed treatment of nondisplaced and nondislocated condylar neck and head fractures versus open reposition internal fixation of displaced and dislocated fractures

OBJECTIVE

assessment of open reduction internal fixation in displaced or dislocated fractures of the condylar neck and head assessed versus closed treatment of nondisplaced, nondislocated fractures.

MATERIALS AND METHODS

One hundred and twenty patients suffering from 158 fractures; classes II to V according to Spiessl and Schroll, e.g., displaced and dislocated fractures were operated on; classes I and VI nondisplaced, nondislocated fractures were treated conservatively. At 1year, facial symmetry, pain, facial nerve function, and scarring were assessed clinically; reossification and fragment angulation were assessed from radiographs; vertical position, incisal maximum movements, and condyle translation were judged by millimeters.

RESULTS AND DISCUSSION

Clinical courses were uncomplicated in classes I to IV and did reach horizontal and vertical fragment reposition with minor remodeling in follow-up. Single cases evinced persistent pain, dysocclusion, facial nerve palsy, and plate fractures. Results were less successful in classes V and VI: although open reposition internal fixation showed good repositioning in class V, marked vertical bone remodeling occurred; single cases suffered from pain, dysocclusion, and plate fracture. Class VI cases had the worst translation, likewise marked condyle remodeling, and frequent dysocclusion.

CONCLUSION

Classes V and VI remain challenging to treat, while the other classes can be treated reliably with this study's rationale. Condyle remodeling in classes V and VI, translation in class VI may benefit prospectively from even more careful mobilization, improved osteofixation as minimalized operation trauma.

A prospective audit over a six month period of condylar fractures at Chris Hani Baragwanath Hospital

OBJECTIVE

To determine the frequency of occurrence, patterns, aetiology and outcome of treatment of mandibular condylar fractures at Chris Hani Baragwanath Hospital.

MATERIALS AND METHODS

All patients with condylar fractures seen at Chris Hani Baragwanath Hospital over a six-month period from January to June 2003 were included in the study. Data was recorded on sex, age, date of injury, cause of trauma, status of the occlusion and presence of associated facial injuries. The type of condylar fracture was recorded and classified following the radiographic examination according to Spiessl and Schroll. The type of treatment rendered and its outcome were also documented. Patients were followed up from 1 week to 6 months post-treatment.

RESULTS

The sample comprised 84 patients with 95 condylar fractures; 69 (82%) males and 15(18%) females. 73.8% of the fractures were caused by interpersonal violence followed by road traffic accidents (16,67%) and falls (7.14%). 73 (87%) patients had unilateral fractures and 11 (13%) had bilateral condylar fractures. Of the 95 condylar fractures, there were 16 medially dislocated condylar fractures in 13 patients. Type I, Type II and Type III fractures accounted for 31%, 26% and 25% of the total fractures respectively.

CONCLUSION

A relationship exists between the type of condylar fracture and the cause of the fracture: road traffic accidents and falls produce more bilateral and dislocated fractures than interpersonal violence. Prolonged intermaxillary fixation, failure to use training elastics, absence of active physiotherapy and poor patient compliance results in increased risk of hypomobility.

[Delayed pan-facial fractures-injury patterns associated with deficient treatment results and clinical classification]

OBJECTIVE

To analyze the injury patterns in pan-facial fractures (PFF) which potentially lead to deficient treatment outcomes and then to propose a clinical classification.

METHODS

Thirty-nine patients, 31 male and 8 female, with an average age of 33, treated from 1998 to 2007 in the Center of Maxillofacial Trauma, Peking University School and Hospital of Stomatology, were included. Zygomatic complex, maxilla and mandible were involved in the extensive fracture concomitant with nasal-orbital-ethmoid (NOE) fracture or not. All cases experienced a delay of over 4 weeks after injury. An analysis was made to display the relationship between facial architecture demolition and disfigurement and disability. Treatment results were assessed with facial appearance, opening range, occlusion and regional deformities. The associated injury patterns most frequently leading to deficient outcomes were summarized as references to scheme a clinical classification.

RESULTS

Facial deformities presented in 90% of the patients and mostly related to condylar fracture/dislocation and zygomatic complex fracture. Limited mouth opening occurred in 59% of patients and were caused most frequently by displacement of zygomatic complex and joint ankylosis. Malocclusion was found in 100% of cases and there were the associated optical signs in 46%. Thirty-nine cases were divided into two types. Zygomatic, maxillary and mandibular fractures all together constituted type I, which accounted for 46% of patients. Type I plus NOE fracture was type II, which accounted for 54% of patients. Furthermore, A, B and C sub-types were recognized in corresponding to involvement of condylar dislocation/fracture and zygomatic complex fracture. In treatment outcomes, a difference between type I and type II fractures remained with NOE fractures. The outcomes of term "moderate" and "worse" in subtype C group were attributed to severe soft tissue injuries and trauma-induced ankylosis.

CONCLUSIONS

NOE fracture, condylar fracture and dislocation, and zygomatic complex fracture were closely associated with deficient treatment outcomes. Correspondingly, an clinical classification was proposed for PFF.

Magnetic resonance imaging findings of temporomandibular joint soft tissue changes in type V and VI condylar injuries

PURPOSE

The objective of this study was to describe the incidence of acute temporomandibular joint (TMJ) soft tissue lesions associated with the occurrence of type V (high condylar fractures with dislocation) and type VI condylar fractures (condylar head fractures).

PATIENTS AND METHODS

The study comprised 11 consecutive patients, who were assigned a diagnosis of a uni- or bilateral type V or type VI condylar fracture. Bilateral sagittal and coronal magnetic resonance (MR) images were obtained immediately after injury to establish the presence or absence of disc disruption, capsular tear, retrodiskal tissue tear, and hemarthrosis.

RESULTS

There was 1 condylar fracture site showing signs of disc disruption (16.7%). Tears in the capsule and retrodiscal tissue were found with an incidence of 77% and 71%, respectively, while the incidence of hemarthrosis accounted for 100%. MR imaging failed to show any signs of soft tissue lesions for condylar nonfracture sites.

CONCLUSIONS

Type V and type VI condylar fracture sites are associated with a high incidence of injuries to the joint capsule and retrodiscal tissue. Investigation of longitudinal evidence, including risk factors, natural history, and response to treatment appears warranted and necessary.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

The mandible injury severity score: development and validity

PURPOSE

To develop and validate a clinical method for characterizing and scoring mandible injury severity.

MATERIALS AND METHODS

Constituent fracture variables (fracture type, location, occlusion, soft tissue involvement, infection, and interfragmentary displacement [FLOSID]) were used to develop the FLOSID taxonomy for characterizing injury. Each component was assigned an empirical weight to help derive a summary measure of injury severity called the UCLA Mandible Injury Severity Score (MISS). Subsequently, MISS values were calculated for a group of 336 patients treated for mandible fractures. The validity of the summary score was evaluated by relating the MISS measure to the treatment modality used and to various variables, related as well as unrelated to injury outcomes.

RESULTS

Each of the FLOSID components correlated significantly with the MISS (P < .001). Unrelated variables, including ethnicity, education, and gender, had no correlation to the MISS. On average, patients treated with rigid internal fixation had a higher MISS than patients treated with maxillomandibular fixation (P < .001). The MISS had a statistically significant association with surrogate markers of injury severity such as sensory nerve deficit, need for hospitalization, and pain at 1-month follow-up (P < .001). However, there was no significant association between MISS and indicators of postoperative complications (infection, nonunion, malunion, malocclusion).

CONCLUSIONS

The FLOSID taxonomy offers a useful alternative to narrative summarization of mandible injury. The MISS is readily derived from clinical parameters obtained at the initial patient encounter and appears to be a valid index of mandible injury severity across important clinical domains.

Unilateral mandibular condylar fractures: a 31-year follow-up of non-surgical treatment

At the University Hospital of Malmö, Sweden, standardized trauma charts were used for registration of all jaw fractures from 1972 to 1976. During the year 2005 the aim was to interview all patients treated non-surgically for unilateral mandibular condylar fractures during this period. In total, 49 patients with unilateral condylar fractures were treated non-surgically in 1972-1976. Of these, 23 patients were available for follow-up, 17 were dead, 7 were not found and 2 did not answer letters or phone calls. The follow-up was a telephone interview according to a standardized questionnaire concerning occurrence of pain and headache, function of the jaw and joint sounds. Information from original records, radiographic reports and the standardized trauma charts revealed fracture site, type of fracture and intermaxillary fixation if any. Eighty-seven percent of the patients reported no pain from the jaws, 83% had no problems chewing and 91% reported no impact of the fracture on daily activities. Neck and shoulder symptoms were reported by 39% and back pain by 30%. The 31-year results of non-surgical treatment of unilateral non-dislocated and minor dislocated condylar fractures seem favourable concerning function, occurrence of pain and impact on daily life.

A comparative study of mandibular fractures in the United States and Turkey

This study compared the data on mandibular fractures that occurred in a city in the United States and one in Turkey between 1991 and 2000. The 210 Turkish patients had 252 mandibular fractures, whereas the 665 US patients had 1042 mandibular fractures. Males accounted for 84% (560 patients) and females for 16% (105 patients) of the cases in the US. The male:female ratio was 5.5:1. In Turkey, males accounted for 76% (160 patients) and females for 24% (50 patients) of cases. The male:female ratio was 3.2:1. Assault (53.7%) was the most common cause of fracture in the US, whereas in Turkey the most common cause was a motor vehicle accident (36.2%). The most common site of mandibular fracture in the US was the angle (27.57%); in Turkey the most common site was the body (28.97%). Many of these variations may be related to socioeconomic, cultural and environmental differences between the two countries.

Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes

Recent studies have suggested magnetic resonance imaging (MRI) as useful in the evaluation of soft-tissue changes that occur in the temporomandibular joint (TMJ) after acute condylar trauma. The aim of this study was to investigate whether MRI findings of disc displacement, capsular tear and haemarthrosis are linked to the degree of condylar injury. Nineteen patients were assigned a diagnosis of uni- or bilateral condylar fracture (n=17), or condylar contusion with a uni- or bilateral diagnosis of TMJ sprain/strain (n=2). Condylar injuries were classified as grade I (absence of condylar fracture), grade II (type I, II or III condylar fracture), and grade III (type IV, V or VI condylar fracture). Bilateral sagittal and coronal MR images were obtained immediately after injury to establish the presence or absence of disc displacement, haemarthrosis and capsular tear. The data revealed a significant relationship between the degree of condylar injury and the MRI findings of capsular tear (P=0.000) and haemarthrosis (P=0.000), and between the MRI diagnoses of capsular tear and haemarthrosis (P=0.000). There was good diagnostic agreement between the presence of grade III condylar injury and the MRI diagnoses of capsular tear (K=0.62) and haemarthrosis (K=0.60). The results suggest that degree of condylar injury is related to MRI findings of capsular tear and haemarthrosis, and that MRI to supplement diagnosis of grade III condylar injury is warranted.

Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals

INTRODUCTION

The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon's experience.

PURPOSE

This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment.

MATERIAL AND METHODS

The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted.

RESULTS

Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively.

CONCLUSIONS

Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.

Management of Mandible Fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Review the incidence and etiology of mandible fractures. 2. Discuss indications and techniques for closed and open treatment of mandible fractures. 3. Review complications of mandible fractures.

BACKGROUND

Mandible fractures are among the most common types of facial fractures treated by plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize secondary complications.

METHODS

Current methods of management include combinations of soft diet, intermaxillary fixation, open reduction with plate fixation, and, rarely, external fixation.

RESULTS

Decision-making depends on the age of the patient, type of fracture identified, and concomitant medical conditions or injuries.

CONCLUSION

The authors review the diagnosis and current trends in management of mandible fractures.

Prospective evaluation of a pragmatic treatment rationale: open reduction and internal fixation of displaced and dislocated condyle and condylar head fractures and closed reduction of non-displaced, non-dislocated fractures

This study prospectively evaluated closed reduction (CR) outcomes in non-displaced, non-dislocated high-condylar and condylar-head fractures (Class VI after Spiessl and Schroll) and open reduction and internal fixation (ORIF) of displaced (Class III) or dislocated (Class V) fractures. Thirty-eight patients with 54 fractures (16 (42%) with bilateral fractures, 14 (37%) CR, 24 (63%) ORIF) were enrolled in a 1 year follow-up that 18 patients with 33 fractures completed. Condylar translation in Class VI fractures recovered to 11 mm for vertical opening, 8mm for protrusion and 10 mm for mediotrusion; Class III synonymously 8 mm, 8 mm and 6 mm; and Class V 7 mm, 6mm and 7 mm; incisal movements recovered to 38 mm, 8 mm and 8 mm in Class VI; 55 mm, 7 mm and 10 mm in Class III with 1 (8%) malocclusion, 1 (8%) impaired vertical opening and 55 mm, 7 mm and 9 mm in Class V with 2 (18%) malocclusions. Fragment-reduction versus the non-fractured condyle was -0.3 mm to +1.3 mm and +3 degrees to +9 degrees in Class VI, -1 mm to -0.2 mm and +3 degrees to +2 degrees in Class III, -3.3 mm to +3.1 mm and -11.2 degrees to +1 degrees in Class V. Malocclusion and joint locking were unreliable determinants for a treatment decision, being forged by concomitant fractures. Joint movements were within normal range at 1-year follow-up except Classes III and V vertical opening translation. After predefined criteria, 92% successful outcomes were attained. Multiple factor analysis should be used to prospectively evaluate the unacceptable clinical outcomes. Class VI fractures with intact vertical support should prospectively be evaluated whether these benefit from ORIF.

Epidemiology of mandibular fractures treated in a Brazilian level I Trauma Public Hospital in the city of São Paulo, Brazil

This article reviews cases of mandibular fractures treated at the Service of Oral and Maxillofacial Surgery of the Hospital Complex of Mandaqui (SUS/SP), which is a reference hospital complex for trauma in the northern area of the city of São Paulo, Brazil. Ninety-eight patients with mandibular fractures were seen at the hospital between January and December, 2001. Out of this total, 91 cases whose files were deemed adequate in terms of data accuracy and completeness were reviewed. The following data were collected for the study: age, gender, etiology, anatomical fracture site, treatment modality, relation to other facial bone fractures, hospitalization time and posttrauma complications. Motorcycle accident was the major cause of mandibular fractures followed by physical aggression and height fall. The mandibular anatomical sites of higher fracture incidence were: body, symphysis and condyle. The most commonly performed treatment modes were conservative approach or open reduction and intraosseous fixation. In conclusion, motorcycle accidents were associated with a larger number of facial fractures and most predominantly affect 21-30 year-old males. On the average, motor vehicle accident victims had more (and more severe) fractures than physical aggression victims. Complications were mostly associated with angle fractures and hospitalization period. Polytraumatized patients presented greater morbidity for complications.

Prospective evaluation of a pragmatic treatment rationale: open reduction and internal fixation of displaced and dislocated condyle and condylar head fractures and closed reduction of non-displaced, non-dislocated fractures

This prospective study evaluated outcomes of closed reduction (CR) in non-displaced, non-dislocated condyle and subcondylar fractures (Class I) and open reduction and internal fixation (ORIF) of displaced (Class II) and dislocated (Class IV) fractures. Forty-five patients with 51 fractures (six (13%) with bilateral fractures), 11 (25%) CR and 34 (75%) ORIF, were enrolled in a 1-year follow up that 20 patients with 25 fractures completed. Condylar translation in Class I fractures recovered to 12mm for vertical opening, 9mm for protrusion, 8mm for mediotrusion; in Class II, respectively, 10, 7 and 9mm; and Class IV, respectively, 8, 7 and 7mm. Incisal movements recovered to 46, 8 and 9mm in Class I; 44, 7 and 9mm in Class II; and 43, 5 and 7mm in Class IV. Vertical and angular fragment reduction versus the non-fractured condyle was +0.3 to -1.9mm, +1.1 degrees to +1.8 degrees in Class I; -2.2 to -1.9mm, +0.6 degrees to -1.2 degrees in Class II; +2.9 to -1.1mm, +18.4 degrees to +6 degrees in Class IV. Malocclusion and joint locking were unreliable determinants for a treatment decision, being forged by concomitant fractures. All complications subsided after 6 months; translation and incisal movements returned to within the normal range in proportion to the severity of displacement and dislocation. Vertical opening translation in Class IV fractures remained short-to-normal and was compensated by rotation. Unacceptable clinical function according to predefined standards was not found after 1 year. Angular reposition was better than vertical reduction. This study documents successful evidence-based treatment according to predefined criteria.

Miniplate osteosynthesis of fractures of the edentulous mandible

This study was performed to analyze treatment of fractures of the edentulous mandible and to discuss this method in relation to the mandibular height at the fracture site. Fifteen fracture sites in 11 patients with an edentulous mandible were retrospectively examined. These fractures were located: nine fractures in the mandibular body, three in the paramedian region, and three in the mandibular angle. Fractures in a mandible measuring more than 10 mm in the vertical height were treated with one miniplate. Fractures in an extremely atrophic mandible with 10 mm or less were treated using one or two miniplates, also using a modified Champy plate with 1.3 mm in thickness. A mandibular fracture with a height of 5 mm was treated with a combination of a microplate on the buccal side and a miniplate on the inferior border of the mandible with additional direct circumferential wiring. Oblique or splitting fractures were treated with direct circumferential wiring or a Herbert screw, at one fracture site each, respectively. Complications, including infection, fibrous union, nonunion and trismus, were not seen. In one patient, hypesthesia of the lower lip was, however, persistent 1 month after surgery. Miniplate osteosynthesis is the less invasive treatment, and it is suitable for fractures of the atrophic edentulous mandible, except for comminuted or defect fractures. To obtain stable fixation in severely atrophic mandibles, we need to consider the use of two miniplates or a combination with microplates.

Fractures de l’angle mandibulaire : facteurs prédictifs des complications infectieuses

INTRODUCTION

Fractures of the mandible angle raise the risk of infectious complications. We searched for factors predictive of these complications.

MATERIAL AND METHODS

We reviewed retrospective all cases of mandibular angle fracture treated during a 26-month period. We compared two groups: fractures with wisdom teeth and fractures without wisdom tooth. For each group we noted clinical and radiological characteristics of the fractures and infectious complications.

RESULTS

The series included 72 mandibular angle fractures, 30 with a wisdom tooth against 42 without. Most of the patients were treated within 2 days, generally using mini-plate screw fixation. In the wisdom tooth group, 16.6% of patients developed infectious complications versus 9.5% in the without wisdom tooth group. All patients of the wisdom tooth group presented a potentially infectious focus on the preoperative x-rays. For without wisdom tooth group, irregular follow-up was found to be the only risk factor.

DISCUSSION

The angular localization increases the risk of infectious complications especially if the wisdom tooth is in the fracture. We propose a decision tree to determine when to preserve or not the wisdom tooth.

[Enteral feeding by nasogastric tube in mandibular fracture osteosynthesis]

INTRODUCTION

Mandibular fractures are among the most common fractures of the face; their treatment consists in a reduction by intermaxillary blocking then miniplate osteosynthesis. In our unit we systematically insert a nasogastric tube for enteral feeding to improve nutrition and to protect healing. Since the beginning of 2002, a series of patients operated for simple mandibular fractures were fed immediately after the operation by a semiliquid food. The purpose of this work is to verify the real advantage of enteral feeding by nasogastric tube in patients operated for simple fractures of the mandible.

MATERIAL AND METHOD

This retrospective study includes all the patients operated for closed fractures of the toothed portion of the mandible from January 1999 to October 2003. There were two series, a first series of patients operated between 1999 and 2002 fed by nasogastric tube until mouth healing and the second series of patients operated between 2002 and 2003 fed by mixed oral-enteral nutrition from the first postoperative day. We analyzed demographic features, time between trauma and operation, type of fracture, feeding modalities, duration of use of the nasogastric tube, duration of hospital stay and postoperative complications.

RESULTS

A total of 111 patients were included in the study. The first group of 81 patients fed by nasogastric tubes included 19 women and 62 men with an average age of 29.7 years (from 15 to 81 years). The average time from trauma to operation was 2.3 days (0 to 5 days), the feeding by nasogastric tubes was maintained 5.9 days after the operation (4 to 12 days), the average hospital stay was 7.2 days (5 to 13 days). Eleven immediate complications were observed (13.6%). The second group of 30 patients fed orally the day after the intervention included 7 women and 23 men. The average time from trauma to operation was 2.2 days (0 to 7 days), the average hospital stay was 2.5 days (2 to 3 days). One complication was observed (3.3%).

DISCUSSION

Immediate oral feeding the day after the operation for simple closed mandibular fractures provides certain comfort for the patient by avoiding the inconveniences of nasogastric feeding tubes without increasing the rate of postoperative complications such as disunion, delayed healing or infection. The hospital stay is significant shortened, enabling a real cost savings.

Subclassification of fractures of the condylar process of the mandible

We present the definitions of various types of fracture of the condylar process, which have been adopted for the Strasbourg Osteosynthesis Research Group (SORG), in their Pan-European prospective randomised controlled trial into the management of such fractures. We think that this will assist people in their description of the various types of fracture of the condylar process.

A prospective randomized clinical trial comparing 2.0-mm locking plates to 2.0-mm standard plates in treatment of mandible fractures

PURPOSE

The purpose of this study was to compare standard 2.0-mm monocortical plates to 2.0-mm locking plates in the treatment of mandible fractures.

PATIENTS AND METHODS

A prospective randomized clinical trial was conducted at Harborview Medical Center in Seattle, WA, from January 1, 2002, to February 1, 2003, to compare 2.0-mm locking plates to 2.0-mm standard plates in treating consecutive mandible fractures. Patients were randomly assigned to receive locking 2.0-mm plates (group A) or nonlocking 2.0-mm plates (group B). Complications were divided into major and minor categories. Each complication was analyzed according to which plate was used and where the fracture occurred. The number of days from injury to operation, average age, gender, American Society of Anesthesiologists (ASA) classification,compliance, and social habits were all reviewed.

RESULTS

Ninety patients with 122 fractures met the inclusion criteria. Sixty-four fracture sites were treated with locking plates and 58 with standard plates. A total of 6 complications occurred: 2 occurred at the angle, 3 at the parasymphysis, and 1 at the body. Three complications occurred in the locking group and 3 in the standard group with complication rates equaling 4.6% and 5.2%, respectively. When comparing the overall complication rates according to plates used, the Fisher exact test showed no statistically significant difference between the locking and standard plates (P = .90). The 95% confidence interval for the odds ratio is from 0.1 to 7.

CONCLUSION

Mandible fractures treated with 2.0-mm locking plates and standard 2.0-mm plates present similar short-term complication rates.

Mandible fracture patterns: a suburban trauma center experience

PURPOSE

Mandible fractures are among the most frequently seen injuries in the trauma center setting. Recent shifts in the mechanism and age distribution of patients sustaining these injuries are well documented. This study attempts to define current, predictable patterns of fracture based on patient characteristics and mechanism of injury.

MATERIAL AND METHODS

The charts of 134 patients with 225 mandible fractures treated over a 7-year period by the Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery and Oral-Maxillofacial Surgery services, our institution, were retrospectively reviewed. Patients were categorized based on age, mechanism of fracture, and anatomic location of fracture. Multivariate analysis of data was performed to determine significant relationships among groups.

RESULTS

Violent crimes such as assault and gunshot wounds accounted for the majority of fractures (50%) in this study, with motor vehicle accidents less likely (29%). Overall, parasymphyseal fractures were most frequent (35%), whereas angle and body fractures were also common (15% and 21%, respectively). There was a statistically significant association of motor vehicle accidents with parasymphyseal fractures (45%), and gunshot wounds with body fractures (36%), whereas assault victims had a higher than predicted frequency of angle fractures (27%) and fewer parasymphyseal fractures (19%). Patients aged 17 to 30 were more likely to suffer from gunshot wounds, whereas older adults (age 31-50) were more likely to be assault victims. Patients over age 50 suffered fractures from falls at a higher than expected rate. Although children and young adults seemed to suffer more parasymphyseal fractures and older adults body fractures, these correlations failed to show statistical significance. Parasymphyseal fractures were most frequently associated with fractures at other sites within the mandible, ipsilateral body fractures being the most common.

CONCLUSIONS

Updated data on the association of patient age and mechanism of injury with fracture pattern can guide treating physicians in anticipating and diagnosing traumatic mandible fractures.

Influence of the Incompletely Erupted Lower Third Molar on Mandibular Angle and Condylar Fractures

BACKGROUND

Several studies have shown an increased risk of mandibular angle fractures by the presence of the lower third molar (M3), especially the incompletely erupted M3. The presence of M3s might influence condylar fractures, which is one of the most common fracture sites, as well as the angle fracture.

METHODS

Six hundred ninety-two mandibular sides among 346 patients with mandibular fracture were analyzed. They were classified into two groups according to the presence of incompletely erupted M3s and were analyzed according to fracture site, age, and cause of injury.

RESULTS

Among these patients with mandibular fractures, the frequency of occurrence of the mandibular angle fracture was higher in the group with incompletely erupted M3s (p < 0.0001) and that of the condylar fracture was higher in the group without it (p < 0.001).

CONCLUSION

The result of this retrospective investigation shows that an incompletely erupted M3 decreases the risk of condylar fractures and increases the risk of mandibular angle fractures.

The correlation between mandible fractures and loss of consciousness

PURPOSE

The purpose of the study was to evaluate the relationship between mandible fractures and loss of consciousness (LOC) in patients sustaining maxillofacial trauma in a level I trauma center.

PATIENTS AND METHODS

The study was a retrospective chart review performed at Lincoln Medical and Mental Health Center, a level I trauma center. A total of 225 hospital charts of patients who sustained mandible fractures during the period from 1997 to 2001 were reviewed. The site of fracture, number of fractures per mandible, degree of displacement, and mechanism of injury were recorded. Percentages of each category were compared among patients with positive and negative LOC. Patients with any concomitant craniofacial fractures or injuries were excluded from the study.

RESULTS

The incidence of LOC in patients sustaining mandible fractures was 17.6%. Young men were most likely to sustain mandibular fractures. The male-to-female ratio was 5.6:1. More than 70% of mandible fractures were due to interpersonal violence. Among various causes of interpersonal violence, use of a fist was most common. Overall, the number of fractures per patient, the incidence of singular versus multiple mandibular fractures, and the degree of displacement were less in the group with positive LOC. Body and angle regions were subjected to higher numbers of fractures, with slight variation among the 2 groups. The most common locations for mandibular fractures were the body (26% in negative LOC group; 42% in positive LOC group) and the angle (31% in negative LOC group; 26% in positive LOC group).

CONCLUSION

Nearly 1 in 5 mandible fractures was associated with positive LOC. The patient group with a positive LOC, on average, sustained fewer fractures. It is possible that when the mandible sustained fewer fractures, the dissipation of energy was reduced and more force was transmitted to the cranial vault, thereby resulting in a higher incidence of LOC.

Perioperative neurosensory changes associated with treatment of mandibular fractures

PURPOSE

The purpose of this study was to document perioperative neurosensory changes in the inferior alveolar nerve (IAN) after mandibular fracture treatment and to identify risk factors associated with these changes.

MATERIALS AND METHODS

This was a prospective cohort study composed of patients treated for mandibular fractures. The primary study variable was the change between the postinjury/pretreatment IAN neurosensory examination score and the score after fracture reduction. Risk factors were categorized as demographic, anatomic, and treatment. Appropriate descriptive, bivariate, and multivariate statistics were computed.

RESULTS

The cohort was composed of 61 patients with 97 fractured sides. Forty-seven fractures (49%) were located between the lingula and mental foramen, and 50 fractures (51%) were located distal to the mental foramen. Thirty-nine fractures (41%) were displaced by 5 mm or more. Abnormal preoperative IAN neurosensory examinations were documented in 81% of the fractured sides. Fifty-three fractures (54%) were treated by closed reduction and 44 (46%) by open reduction and internal fixation. In 82 fractures (85%), the IAN neurosensory score was unchanged or improved after treatment. In a multivariate model, preoperative neurosensory score, displacement, and treatment were associated with a statistically significant risk (P < or =.05) for postoperative deterioration of IAN sensation.

CONCLUSION

Open reduction and internal fixation, fracture displacement of 5 mm or more, and a normal preoperative IAN neurosensory examination were associated with an increased risk for deterioration of the IAN neurosensory score after treatment of mandibular fractures. Additional studies are indicated to determine long-term IAN neurosensory function after mandibular fracture treatment and the factors that affect prognosis.

Etiology and Patterns of Pediatric Mandibular Fractures in Portugal: A Retrospective Study of 10 Years

OBJECTIVE

To determine the pattern of occurrence of mandibular fractures in the pediatric population in Portugal.

MATERIALS AND METHODS

This retrospective study reviews the records of patients 18 years of age or younger from the 10-year period 1993 to 2002. Age, gender, anatomic site, cause of the accident, weekly and monthly variation, location and type of fractures, presence and location of associated injuries, treatment methods, and complications were reviewed.

RESULTS

During this 10-year period, 521 patients with 681 mandibular fractures were treated. Motor-vehicle accident (MVA) was the most common (53.9% patients) cause of fracture. Almost half of the patients (48.8%) were in the oldest age group (16 to 18 years old). The condyle of the mandible was involved in 31.0% of the fractures. Maxillomandibular (MMF) fixation was used in 534 (78.4%) fractures. Overall mortality in this series was 0.6% (3 patients); mortality was caused by multiple traumas, mainly head trauma.

CONCLUSION

There is a need to reinforce legislation aimed to prevent MVA and the total enforcement of existing laws to reduce maxillofacial injuries among children and adolescents.

Mandibular condyle fractures: determinants of treatment and outcome

PURPOSE

The objective of this study was to analyze the principal variables that determine the choice of the method of treatment and the outcome in condylar fractures.

MATERIALS AND METHODS

We conducted a retrospective analysis of 104 mandibular condyle fractures to analyze and determine the relation between the principal clinical variables and the postoperative results. All patients underwent a clinic-radiologic investigation focusing on fracture remodeling, evolution, dental occlusion, and symmetry of the mandible. We analyzed the influence of the preoperative clinical variables (level of fracture, treatment, postoperative physical therapy, displacement and dislocation, comminution, loss of ramus height, patient age, gender, etiology, occlusion, status of dentition, and presence of facial and mandibular fractures) over the postoperative results and outcome.

RESULTS

The principal factors that determined the treatment decision were the level of the fracture and the degree of displacement. The level of the fracture influenced the degree of preoperative coronal and sagittal displacement (neck fractures had greater medial and anterior displacement than head and subcondylar fractures) and the treatment applied. The functional improvement obtained by open methods was greater than that obtained by closed treatment. Open treatment increased the incidence of postoperative condylar deformities and mandibular asymmetry.

CONCLUSION

The variables that influenced the method of treatment and predicted the prognosis are the level of fracture, degree and direction of displacement of the fractured segments, age, medical status of the patient, concomitant injuries, and status of dentition.

Stabilit�t der Osteosynthese bei Gelenkwalzenfrakturen in Klinik und biomechanischer Simulation

BACKGROUND

Fractures of the condylar head are traditionally managed by closed techniques, despite a considerable rate of dysfunctional problems. PDS pin osteosynthesis (presented by Rasse 1992) via a preauricular approach failed to become established as a standard procedure due to a lack of stability. Alternatively, mini- or microplating, as performed in our patients (101 condylar head fractures between 1993 and 2000), showed high-grade limitations of translatory movements in about 30% due to scarification after loosening of osteosynthesis materials. The aim of this study was to establish an efficient procedure for achieving a functionally stable and atraumatic osteosynthesis.

METHODS

For the definition of a suitable procedure, models of the mandible (standardized fractures, types A, B, and C) were osteosynthesized (six samples for each type of fracture and type of screw), each with three PDS pins, 2.0 mm resorbable, 2.0 cortical, 1.7 and 1.2 mm small fragment screws, and exposed to increasing loads in centric (0-20-35 mm opening) and eccentric (35 mm opening) condylar positions. A computerized biomechanical test stand allowed a dynamic simulation of chewing forces (16 hydraulic drives). The resulting fracture gaps were measured without contact by a motion capture system.

RESULTS

Within physiological limits, only 1.7 small fragment and 2.0 mm cortical screws were able to bear occlusal loadings up to 200 N (1.2 mm small fragment screws up to 150 N, resorbable 2.0 mm screws up to 100 N, and PDS-pins up to 50 N). In a pullout experiment (condylar spongious bone of young pigs, aged 4-6 months), 1.7 mm small fragment screws showed superior retention. A consecutively developed small fragment screw-system has been applied clinically in 74 condylar head fractures (58 patients). After removal of osteosynthesis material, 41 of 49 TM joints have so far shown complete restitution.

CONCLUSIONS

The newly developed osteosynthesis system using a retroauricular approach based on 1.7 mm small fragment screws makes maxillomandibular immobilization unnecessary. The extra-articular position of the screw heads prevents scar-induced articular limitations. Preexisting degenerative alterations of the TMJ soft tissues, however, will affect functional results adversely.

Endoscopic mandibular condyle fracture repair

Treatment of mandibular condyle fractures remains a controversial issue. Arguments center on the relative merits of open versus closed treatment. In the past decisions were largely based on philosophy, anecdotal experience, and retrospective case series with short follow-up. Well-designed studies have now begun to appear in the literature and suggest improved results after open, anatomic reduction and fixation. Many surgeons are still hesitant about liberally applying the open approach due to the resultant facial scarring and the risk of facial nerve injury. Developments in endoscopic technology have recently been applied to facial fracture repair. The endoscopic approach to mandibular condyle fracture repair reduces the risk of facial nerve injury, and dramatically reduces facial scarring, compared with standard open approaches. We feel that the reduced morbidity of the endoscopic approach may allow the benefits of anatomic reduction and rigid fixation to be offered to a larger proportion of patients with mandibular condyle fractures. Technical and technological advances are expected to aid in the dispersal of these techniques in the future.

Complications of mandibular fractures in an urban teaching center

PURPOSE

In this study, we compared the complications associated with open and closed treatment of mandibular fractures in an urban teaching center over a 4-year period.

PATIENTS AND METHODS

We conducted a retrospective review of mandibular fracture morbidity associated with treatment by the oral and maxillofacial surgery service between 1996 and 2000. A total of 721 fractures were recorded, with 594 fractures available for review. Perioperative and postoperative complications were assessed by reviewing patient charts, operative reports, and radiographs. Complications were classified by location, type of complication, and treatment modality. Standard statistical tests were used to assess differences between the groups.

RESULTS

Of the 594 fractures available for review, a total of 79 fractures were noted to have had a complication (13.3%). One hundred five complications were observed in the group of 79 fractures due to more than one complication being associated with a specific fracture (15.8%). Closed reductions accounted for the largest treatment group, representing 341 fractures with 26 complications (7.6%). Miniplate fixation was used in 97 cases, with 23 complications (23.7%). Mandibular plates with or without a superior border miniplate were used in 140 fractures, with 28 complications (20%). The most common complication was wound infection, which occurred in 35 fracture sites, followed by nonunion, which occurred at 30 sites.

CONCLUSION

In an urban area with a high prevalence of poor living conditions, substance abuse, and poor patient compliance, the treatment of mandibular fractures by closed reduction resulted in the least number of postoperative complications in all anatomic regions of the mandible. The mandibular angle fracture had the highest overall morbidity rate.

Determinants of surgical decisions about mandible fractures

PURPOSE

The study goal was to explore contextual patient- and surgeon-related characteristics that influence the perception of injury severity and treatment strategy for mandible fractures.

METHODS

After reviewing plain radiographs of 22 patients with mandible fractures, 18 oral and maxillofacial surgeons were queried on summary severity ratings and treatment decisions for each injury. Subsequently, they were asked to indicate how various hypothetical fracture and patient-specific factors would alter their perception of injury severity and original treatment recommendations. The effect of the level of clinician trauma expertise on perception of injury severity and treatment choice was also assessed.

RESULTS

Each of the fracture-specific characteristics-number of constituent fractures, fracture complexity, degree of displacement, and summary injury severity-influenced the choice of treatment modality. Surgeon-specific characteristics were related to both perception of injury severity and treatment choice. Although clinicians with greater trauma loads tended to provide higher summary severity ratings for the same range of injuries (P <.001), they appeared to recommend maxillomandibular fixation for a much broader spectrum of injury severity (R = -0.42). Surgeons' perception of injury severity appeared to escalate with increasing damage to the soft tissue envelope; the influence of patient-related risk factors was less distinct. More than half of the surgeons suggesting maxillomandibular fixation for a particular case changed their treatment recommendation to rigid internal fixation on learning that the patient was noncompliant.

CONCLUSIONS

Clinical decision making for mandible fractures is not a precise and fully reliable activity. Contextual factors (fracture, patient, and surgeon related) appear to influence the clinical decision and may be responsible for the existing variations in practice patterns.

Maxillofacial war injuries during the Iraq-Iran War: an analysis of 300 cases

The following study focuses on three hundred maxillofacial war casualties that were admitted to the Basra Republic Hospital during the Iraq-Iran War. These three hundred cases were chosen on the basis of them being only oral and maxillofacial injuries. Of these cases, there was no mortality recorded. This was in part due to the rapid evacuation, immediate resuscitation and proper management of the casualties. An appropriately staffed hospital, efficient surgical techniques and the presence of highly skilled specialists working as a team also made this result possible. This analysis categorizes, evaluates and discusses the treatment of the casualties based on the severity of the injury and outlines several techniques used to treat such patients.

Evaluation of stress patterns generated by reduction forceps within a photoelastic mandibular model

INTRODUCTION

Little attention has been paid to the mechanical effects of fracture reduction forceps.

AIM

This study aims to evaluate the stress patterns within the fractured mandible generated by reduction forceps.

MATERIAL AND METHODS

Thirty-six mandibular models were fabricated using a photoelastic resin. Each of the three sets of mandibular models was osteotomized according to one of three different fracture types. After reducing the cut segments, reduction forceps were placed into different engagement holes to compress the segments. Photoelastic stress analysis was used to visualize the stress patterns within the fractured mandibular models as generated by the reduction forceps.

RESULTS

In the case of symphyseal or parasymphyseal fractures, an optimum distribution of stresses over the fracture site was achieved when placing the reduction forceps more than 12mm away from either side of the fracture line, between the midway level of the mandibular height (bisecting the mandible) and 5mm below this level. In the case of body fractures, optimum stress distribution was achieved when the reduction forceps were placed more than 16mm from the fracture line at the midway level.

CONCLUSION

Correct use of the reduction forceps helps to provide a precise three-dimensional reduction for mandibular fractures.

An assessment of maxillofacial fractures: a 5-year study of 237 patients

PURPOSE

This descriptive analytical study assesses the cause, type, incidence, demographic, and treatment data of maxillofacial fractures managed at our medical center during a 5-year period and compares them with the existing body of literature on the subject.

PATIENTS AND METHODS

A 5-year retrospective clinical and epidemiologic study evaluated 237 patients treated for maxillofacial fractures from 1996 to 2001 at one medical center. There were 211 male patients (89%) and 26 (11%) female patients. The patients ranged in age from 3 to 73 years, with 59.0% (140 patients) in the 20- to 29-year age group. A number of parameters, including age, gender, cause of injury, site of injury, type of injury, treatment modalities, and complications, were evaluated. All maxillofacial injuries were assessed and treated by a single oral and maxillofacial surgeon. Other concomitant bodily injuries were treated by appropriate consultant specialists.

RESULTS

There were 173 (72.9%) mandibular, 33 (13.9%) maxillary, 32 (13.5%) zygomatic, 57 (24.0%) zygomatico-orbital, 5 (2.1%) cranial, 5 (2.1%) nasal, and 4 (1.6%) frontal injuries. Car accidents caused 73 (30.8%), motorcycle accidents caused 55 (23.2%), altercations 23 (9.7%), sports 15 (6.3%), and warfare caused 23 (9.7%) of the maxillofacial injuries. Regarding distribution of mandibular fractures, 32% were seen in the condylar region, 29.3% in the symphyseal-parasymphyseal region, 20% in the angle region, 12.5% in the body, 3.1% in the ramus, 1.9% in the dentoalveolar, and 1.2% in the coronoid region. The distribution of maxillary fractures was Le Fort II in 18 (54.6%), Le Fort I in 8 (24.2%), Le Fort III in 4 (12.1%), and alveolar in 3 (9.1%). Of the 173 mandibular fractures, 56.9% were treated by closed reduction, 39.8% by open reduction, and 3.5% by observation only. Of 33 maxillary fractures, 54.6% were treated using closed reduction, 40.9% using open reduction, and 4.5% with observation only. Approximately 52.1% of the patients were treated under general anesthesia, and 47.9% were treated under local anesthesia and sedation. Postsurgical complications were recorded in 5% of patients. These complications included infection, asymmetry, and malocclusion. Overall mortality in this series was 0.84% (2 patients); mortality was caused by pulmonary infection.

CONCLUSION

The findings of this study, compared with similar studies reported in the literature, support the view that the causes and incidence of maxillofacial injuries vary from 1 country to another.