Abstract
Aim
This study is designed to outline the probable patterns of mandibular fracture based on patient demographics and mechanism of injury in a rural setup.
Materials and Methods
The data from the record section in our unit belonging to patients who sustained fractures in the maxillofacial skeleton and were treated in our unit between the period June 2012–May 2019 were collected and analyzed. The variables analyzed for the study were etiology, gender, age, and type of fracture. All cases were treated by open reduction and rigid internal fixation.
Results
A total of 224 patients with maxillofacial fractures were diagnosed, of which 195 were male and 29 were female. The ages ranged from 7 to 70 years. Road traffic accidents are noted to be the most common cause of mandibular fractures. The maximum cases were in the age group of 21–30 years with 85 (38%) patients. In a total of 224 patients, there were 278 mandibular fractures. The maximum incidence of fractures was in the mandibular parasymphysis region with 90 fractures accounting for 32.3% of the mandibular fractures. Males were more susceptible to mandibular fractures. Majority of them sustained mandibular fracture at more than one anatomical area.
Conclusion
It can be concluded that mandibular fractures are seen predominantly in the second and third decades of life due to road traffic accidents with high-speed vehicles and lack of protective safety accessories. Mandible when it fractured, it usually involved more than one anatomical location.
Keywords: Mandible, Fracture, Road traffic accidents
Introduction
In spite of the mandible being the largest and the strongest bone of the facial skeleton, it is the second most commonly fractured bone after the nasal bones [1]. The pattern of mandibular fracture varies based on the etiological factor [2]. In developing countries like India, RTA and domestic violence have become the forerunners in the etiological factors for mandibular fractures.
The magnitude and the direction of force delivered in addition to the anatomical area to which it is delivered determine the pattern of fracture. The literature is replete with articles throwing light on the incidence, diagnosis, and treatment of mandibular fractures [3, 4]. However, there is an inadequate understanding pertaining to the specific type or pattern of mandibular fractures particularly those that occur in a rural setup. Hence, this study is designed to outline the probable patterns of mandibular fracture that occur in a rural setup.
Materials and Methods
An observational cross-sectional study was conducted based on the records of patients treated for mandibular fractures in our unit during the period June 2012–May 2019. A total of 224 patients who sustained a mandibular fracture and were treated for open reduction and internal fixation in our unit were included. Patients who sustained a hairline fracture and did not require intervention, pediatric patients and patients who were lost for follow-up were not included. Considering the fact that the study was done in a rural setup, most of the patient could not even afford radiological investigations and surgical intervention. Few patients who underwent surgical intervention failed to report back for follow-up. Hence, only those patients whom we could manage surgically and could follow-up subsequently for at least one year to see their after effects were included. In order to obtain the data, inpatient record of the patients, their plain radiographs, computed tomography data, and clinical photographs were reviewed. Details pertaining to the patient’s age, sex, etiology, pattern of fracture, and treatment were noted.
Patients were divided into seven age groups ranging from 0–10, 11–20, 21–30, 31–40, 41–50, 51–60, and 61 and above. The etiological factors were categorized into road traffic accidents, interpersonal violence, self-fall, sports injuries, influence of alcohol, etc. The location of the fractures was categorized into symphysis and parasymphysis, body, angle, ramus, coronoid, and condyle fracture of the mandible. Mandibular fracture associated with other facial bone fractures was also recorded. Mandibular fractures and its relation with seasonal variation are also recorded.
Results
A total of 224 patients who sustained a mandibular fracture and were treated for open reduction and internal fixation in our unit were included in this study. The recorded data were analyzed using the Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL, USA) software, version 21. Descriptive statistics which included computation of frequency and percentages and Chi-square tests were performed. Confidence interval was set at 95%. p value < 0.05 was considered statistically significant.
Among the 224 patients, 195 were male and 29 were female as shown in Fig. 1. The age ranged from 7 to 70 years with a mean age of 28 years. Mandibular fractures were most commonly noticed in the age group of 21–30 years comprising of 85 (38%) patients followed by 11–20 years age group comprising of 56 patients (28%) as shown in Fig. 2 and Table 1.
Fig. 1.
Graph showing sex distribution
Fig. 2.
Graph showing age distribution
Table 1.
Age and sex distribution of mandibular fractures
| Age | Male | Female | Total (%) | Chi-square value | df | p value |
|---|---|---|---|---|---|---|
| 0–10 | 2 | 0 | 2 (1) | 6.452 | 6 | 0.374 (NS) |
| 11–20 | 52 | 4 | 56 (28) | |||
| 21–30 | 71 | 14 | 85 (38) | |||
| 31–40 | 38 | 9 | 47 (21) | |||
| 41–50 | 22 | 2 | 24 (11) | |||
| 51–60 | 5 | 0 | 5 (2) | |||
| > 61 | 5 | 0 | 5 (2) | |||
| 195 (87) | 29 (13) | 224 |
Inference: There was no statistically significant association between gender and age during fracture (p value 0.374)
Most common etiological factor accountable for mandibular fracture was road traffic accident accounting to 154 patients (69%) followed by interpersonal violence in 31 patients (14%) as shown in Fig. 3 and Table 2. In 224 patients, 278 mandibular fractures were noted. Among the 224 patients, 188 patients (83.9%) sustained only a mandibular fracture. The remaining 36 patients (16.1%) sustained a mandibular fracture which was associated with other facial bone fractures with ZMC being the most commonly involved as shown in Table 3. In the 118 patients who sustained pure mandibular fracture, 100 patients (53%) sustained a mandibular fracture at more than one anatomical region as shown in Fig. 4.
Fig. 3.
Graph showing etiological factors for mandibular fractures
Table 2.
Etiology of maxillofacial fractures according to sex
| Etiology | Male | Female | Total (%) | Chi-square value | df | p value |
|---|---|---|---|---|---|---|
| RTA | 139 | 15 | 154 (69) | 12.383 | 6 | 0.053 (NS) |
| IPV | 26 | 5 | 31 (14) | |||
| Self-fall | 15 | 8 | 23 (10) | |||
| Alcohol | 4 | 0 | 4 (2) | |||
| Animal attack | 9 | 1 | 10 (4) | |||
| Sports | 1 | 0 | 1 (0.5) | |||
| Others | 1 | 0 | 1 (0.5) | |||
| Total | 195 | 29 | 224 |
Inference: There was no statistically significant association between gender and etiology of fracture (p value 0.053)
Table 3.
Table showing isolated mandibular fractures and mandibular fractures associated with other facial bone fractures
| Anatomical area | Male | Female | Total (%) | Chi-square value | df | p value |
|---|---|---|---|---|---|---|
| Mandible | 137 | 25 | 188 (83) | 6.358 | 3 | 0.095 |
| Mandible + ZMC | 31 | 0 | 31 (14) | |||
| Mandible + Nasal | 3 | 0 | 3 (2) | |||
| Mandible + Lefort-I | 2 | 0 | 2 (1) | |||
| 224 |
Inference: There was no statistically significant association between gender and site of fracture (p value 0.095)
Fig. 4.
Graph showing isolated mandibular fractures based on anatomical distribution
The mandibular parasymphysis area is the most commonly fractured anatomical area in the mandible accounting for 90 fractures (32.3%) followed by the condyle of the mandible accounting for 68 fractures (24,4%) as shown in Table 4. Results of this study show that the fractures on the left side of the mandible were more common than the right side. The parasymphysis fractures were more noted in the right side, while the condylar fractures were more on the left side as shown in Fig. 5.
Table 4.
Table showing mandibular fractures based on anatomical distribution
| Site | Male | Female | Total (%) | Chi-square value | df | p value |
|---|---|---|---|---|---|---|
| Symphysis | 6 | 1 | 7 (4) | 9.082 | 7 | 0.246 (NS) |
| Para symphysis | 21 | 9 | 30 (16) | |||
| Body | 12 | 1 | 13 (7) | |||
| Angle | 18 | 0 | 21 (11) | |||
| Ramus | 1 | 0 | 1 (0.6) | |||
| Condyle | 13 | 2 | 15 (8) | |||
| Coronoid | 1 | 0 | 1 (0.6) | |||
| Two or more | 84 | 16 | 100 (53) | |||
| 156 | 29 | 185 |
Inference: There was no statistically significant association between gender and site of fracture (p value 0.246)
Fig. 5.
Graph showing mandibular fracture patterns
Discussion
The etiology for maxillofacial fracture varies from one geographical area to another and the age group of the victim. The literature reveals that road traffic accidents are the main reasons for mandibular fractures in developing countries, while interpersonal violence is the most common cause in developed countries [4–6]. Our results are in accordance with the previous studies. Numerous factors are responsible for such road traffic accidents in developing counties like India. Poor quality of roads, narrow roads, refusal to follow traffic rules, and using safety precautions like helmets have been identified as the main reasons for such a high rate of road traffic accidents [4]. In addition to this, drunken driving is identified to be the main reason for road traffic accidents leading to a mandibular fracture especially in rural areas.
Studies reveal that there is a high prevalence for maxillofacial fractures in males. This could be attributed to the fact that most of the two-wheeler riders are males and that they resort to drunken driving frequently. The results of this study show that out of 224 patients, 195 were male and 29 were female which show that 87% of the patients who sustained a mandibular facture in this study were males. This is in accordance with previous studies [3, 4, 7–9].
Generally, mandibular fractures are seen more commonly in younger males. Majority of the patients in this study were in the age group of 21–30 years accounting for 85 patients accounting for 38%. This is in accordance with previous studies [7–11]. A recent study showed the maximum incidence of mandibular fractures in the third and fourth decades of life attributing to more social interactions and reckless driving [12].
Pertaining to the anatomical area involved, the most frequent anatomical area of the mandible that sustained a fracture was the parasymphysis region with 90 fractures accounting for 23.3%, including five bilateral fractures followed by 68 in the mandibular condylar region with 11 bilateral involvements. There were 56 mandibular angle fractures. Thirty-seven fractures were noted in the mandibular body region.
The literature in the past has shown that the mandibular condylar region is the most commonly fractured anatomical region in the mandible [12–14]. In contrary, few studies have shown the mandibular body to be the most vulnerable region for fracture in the mandible [15, 16]. However, the results of this study show that the parasymphysis region is the most commonly fractured anatomical region in the mandible. This is in accordance with few studies [4, 9].
Based on the data available from the previous studies, it can be concluded that when an individual sustains a mandibular fracture due to a road traffic accident, there are high changes of a parasymphysis or a condylar fracture, whereas when an individual sustains a mandibular fracture due to an interpersonal violence or a fall, there are high changes of an mandibular body or angle fracture.
Fractures on the left side of the mandible were more common than the right side. This is in accordance with the previous studies [9]. With regard to the seasonal distribution, it was noted that the incidence of fractures showed an annual increase from 2012 to 2013, followed by a slight decline in 2014 and 2015 followed by an increase in 2016 to 2019. However, the variation was minimal. This is in accordance with the previous studies [9]. September and March had the highest incidence of fractures, with February being the lowest. This is in accordance with the previous studies [9].
Considering the fact that it is a retrospective study, there could be limitations in the study due to poor record keeping or inadequate data from the available patients’ records. Therefore, a larger data-based prospective study may aid in enhancing the findings of the present study and ascertain subsequent changes in the trend and pattern of these fractures. However, since the literature does not have sufficient data pertaining to the pattern of mandibular fractures in a rural setup, the results of this study can add value to the existing literature.
Conclusion
The mandible being the most prominent and the most movable of the facial bones is more susceptible to injury when compared to the other bones of the facial skeleton. The results of this study show that mandible sustained a fracture primarily due to RTAs and was predominantly seen in the second and third decade of life. The parasymphysis region was the most commonly fractured anatomical region followed by the condylar region. The pattern of fractures noted in the study was not that of the classical one. In majority of the cases, the mandible fractured either at more than one anatomical region or was associated with fracture of other facial bones.
Funding
Self funded.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
Institutional ethical clearance not required.
Informed Consent
Patient consents not required.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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