AMHSR
Mahmood Samman, Syed Waheed Ahmed, Hassan Beshi, Turki Abdulaziz Almohammadi* and Santosh R Patil
 
College of Dentistry, Al Jouf University, Sakaka, Aljouf, Saudi Arabia
 
*Correspondence: Turki Abdulaziz Almohammadi, College of Dentistry, Al Jouf University, Sakaka, Aljouf, Saudi Arabia, Tel: +966 14 624 7493, Email: [email protected]

Citation: Samman M, et al. Incidence and Pattern of Mandible Fractures in the Madinah Region: A Retrospective Study. Ann Med Health Sci Res. 2017; 7: 359-364

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Abstract

Objectives: To study the incidence and pattern of mandible fractures in the holy city of Madinah in the Kingdom of Saudi Arabia over a retrospective period of three years from 2013 (1434H) – 2016 (1436H) and to compare the results with those from other regions of Saudi Arabia and elsewhere. Materials and Method: Relevant data of patients admitted in the King Fahad Hospital, Madinah with fracture of the Mandible during the study period was collected from their medical records and radiographs. The age, gender, etiology, role of the patient, site and number of fractures in the patients were evaluated. The data was analysed by standard statistical methods. Results: One hundred ninety seven patients with fracture of the mandible were admitted in the period of the study by the Oral Maxillofacial surgery department, King Fahad Hospital, Madinah. There were 165 male and 32 female patients. The ages ranged from 3 to 86 years with a mean of 24years. A total of 260 fractures of Mandible were documented. The largest number (113) of patients was found in the age group between 16 – 30 years. Trauma caused by motor vehicle road traffic accidents was the main etiology of the fractures followed by falls and assault. Majority of the patients were in the role of vehicle drivers. The condylar anatomical site of mandible was most frequently affected and constituted the largest number (103) of fractures followed by the angle (51), parasymphysis (45) and then by the body (23) of the mandible. Dentoalveolar fractures were present in 22 cases. Very less number of coronoid fractures (7), followed by those of the ramus (5) and least number at the symphysis (4) of the mandible were found. Conclusion: Road traffic accident was the most common etiology for trauma and fracture of the Mandible. The males outnumbered the female patients, the largest number of patients with trauma and mandible fracture was found in the age group between 16 – 30 years and frequency of condylar fractures was higher.

Keywords

Madinah; RTA; Mandible; Fracture; Behaviour

Introduction

Road traffic accidents are the leading cause of all trauma admissions in hospitals worldwide. [1] Saudi Arabia ranks second after Oman among Arab countries and 23rd globally in terms of deaths due to road accidents, accounting for 4.7% of all mortalities compared to 1.7% in the UK and USA. [2,3] Trauma, chiefly due to the road traffic accidents places a huge burden on the health care service in Saudi Arabia associated with a high morbidity and mortality. The incidence of maxillofacial trauma with fractures of the facial bones is very common and forms a major portion in the workload of an Oral and Maxillofacial surgeon in this country.

The Mandible is particularly more prone for maxillofacial trauma and fractures due to its unique mobility, shape and chin prominence in the facial skeleton. It is the second, most frequent of the facial bones affected by traumatic injuries and shown to account for 15.5% to 59% of all facial fractures. [4] The mandible can be seen fractured alone or in combination with fracture of other bones in the maxillofacial region. A broken lower jaw is accompanied by pain, deranged occlusion and loss of masticatory function, speech impairment and aesthetic disfigurement with psychological effects apart from significant financial cost. [5,6]

The epidemiology of Mandible fractures is highly variable with time among several countries. The mechanism of injury or etiology is also inconsistent in the literature. Etiology of fracture is multifactorial and based variably on socio-economic status, culture, technology, demography and economic factors. [7]

Purpose of our study was to evaluate the incidence, etiology and pattern of fractures of the Mandible in the Holy city of Madinah over a retrospective period of three years from 2013 - 2016 and to compare the results with those from other regions of Saudi Arabia and elsewhere.

Materials and Methods

This was a retrospective study of the incidence and pattern of Mandible fractures in the Holy city of Madinah over a period of three years from 1434H (2013) – 1435H (2016) amongst patients admitted in the King Fahad Hospital, Madinah. The King Fahad Hospital, Madinah is a major referral MOH hospital with 500 beds receiving all trauma cases over a catchment area of 450 km radius.

Relevant data of patients with fracture of the Mandible during the study period was collected from their medical records and radiographs. The age, sex, etiology, role of the patient, site and number of fractures in the patients were evaluated.

The data was analysed by standard statistical methods using SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA), by applying chi-square test.

Results

Majority of the patients in this study were males (165) compared to females (32) with a male: female ratio of 5.15: 1. One hundred ninety seven patients with fracture of the Mandible were admitted in the period of the study with the age of the patients ranging from 3 to 86 years and a mean age of 24 (23.93) years [Table 1]. Trauma caused by road traffic accidents in 178 patients with a frequency of 90.35% was the main etiology of mandible fractures in this study. This was followed by falls in 12 patients (6.09%) and Assault or inter-personal violence in 5 patients (2.53%). Only two patients had sport related injury [Table 2].

Age Group (years) Male (%) Female (%) Total number of Patients Chi square test
t p
1 →15 34 (77.27) 10 (22.72) 44 155.62 0.000
16 →30 100 (88.49) 13 (11.50) 113
31 →45 21 (77.77 6 (22.22) 27
46 → 60 7 (70) 3 (30) 10
61 →75 1 (100) 0 1
76 →Above 2 (100) 0 2
Total 165 (83.76) 32 (16.24) 197

Table 1: Age and gender distribution of study population.

Etiology Male Female Number of Patients (%)
Falls 10 2 12 (6.09)
Road Traffic Accidents 149 29 178 (90.35)
Interpersonal Violence 4 1 5 (2.53)
Sports Injury 2 0 2 (1.01)
Total 165 32 197 (100)

Table 2: Distribution of the Mandibular fractures according to Etiology.

Majority of the patients (114, 57.86%) were motor vehicle (car) drivers and all of them were males. 64 or 14.72% of the number of patients were occupants in the vehicle with 35 males and 29 females [Table 3]. The mandibular condyle was the most common site of fracture in this study found in a vast majority of trauma patients (n-103, 39.61%) involving 95 males and 8 females followed by the mandibular body, angle and parasymphysis [Table 4]. Majority of patients (n-96, 48.73%) had unilateral type of mandibular fractures followed by 72 (35.54%) patients with bi-lateral fractures [Table 5].

Role M F Number of Patients
Vehicle Car Driver 114 (100%) 0 114 (57.86%)
Occupant 35 (54.68%) 29 (45.31%) 64 (32.48%)
Bicycle rider 10 (100%) 0 10 (5.07%)
Motor Cyclist 2 (50%) 2 (50%) 4 (2.03%)
Pedestrian 3 (75) 1 (25%) 4 (2.03%)
Worker 1 (50%) 0 1 (0.3%)
Total 165 (83.75%) 32 (16.24%) 197 (100%)

Table 3: Distribution of Mandibular fractures according to Role.

Anatomical site Male Female Number of Fractures (%)
Dentoalveolar 12 4 22 (8.46)
Symphysis 4 0 4 (1.53)
Parasymphysis 27 8 45 (17.30)
Body 16 4 23 (8.84)
Angle 30 8 51 (19.61)
Ramus 5 0 5 (1.92)
Coronoid process 7 0 7 (2.69)
Condylar process 65 8 103 (39.61)
Total 165 32 260

Table 4: Distribution of Mandibular fractures according to Location.

Type of Fractures Number  (%)
Unilateral # 96 48.73
Bilateral #’s 72 35.54
Multiple #’s 29 14.72
Total (Patients) 197 100

Table 5: Distribution of Mandibular fractures according to Type.

Multiple fractures or fracture in more than two sites were noted in 29 (14.72%) patients. The most common combination of bilateral fractures in our study is condyle with parasymphysis in 18 patients [Table 6].

Fracture Combination Number  (%)
Parasymphysis with Angle # 9 17.64
Parasymphysis with Body # 6 11.76
Parasymphysis with Condyle # 18 35.29
Parasymphysis with Ramus # 3 5.88
Body with Condyle # 4 7.84
Body with Angle # 6 11.76
Angle with Condyle # 5 9.80
Total 51 100

Table 6: Combination of Mandibular fractures (N – 51/260; 19.61%).

Bilateral and similar site fractures of Mandible were found in 36 patients and most of these were bilateral Angle fracture (n-16; 44.44%) followed by bilateral condylar fractures in 13 patients (36.11%). 5 patients had bilateral parasymphysis (13.88%) and two patients (5.55%) had bilateral body fracture of the mandible [Table 7].

Fracture Number  (%)
Bilateral Angle #’s 16 44.44
Bilateral Condylar #’s 13 36.11
Bilateral Parasymphysis #’s 5 13.88
Bilateral Body #’s 2 5.55
Total 36 99.98%

Table 7: Bilateral (Similar Site) Mandibular fractures.

Discussion

Our study revealed 260 fractures of the mandible in 197 maxillofacial trauma patients over the retrospective study period of three years between 2013 (1432H) and 2016 (1436H).

Mandibular fractures have been reported as significantly more common than middle-third facial fractures in many countries. [3-8]. Variation is noted in the number of fractures of mandible in different regions of Saudi Arabia due to differences in regional factors, sample size and period of the studies done. [9-14] [Table 8].

No Author Year Region Number of Mandibular Fractures
1 Alanazi et al. [12] 2016 Qurayyat 452
2 Ahmed et al. [11] 2015 Jeddah 722
3 Almasri et al. 2015 Makkah 523
4 Abdullah et al. [9] 2013 Riyadh 132
5 Nwoku et al. [13] 2004 Riyadh 466
6 Rabi et al. [14] 2002 Madinah 280
7 Present study 2016 Madinah 197

Table 8: Number of Fractures of Mandible reported in some regions of Saudi Arabia.

A male to female ratio ranging between 2.9: 1 to 7.1: 1; and above has been reported from many other countries. [5-8] Studies in some cities of the Kingdom have reported a M: F ratio of 4.4:1; in Makkah [10] M: F ratio6:1 both in Riyadh and Jeddah [9,11] and M: F ratio of 2.1:1; in Qurayyat city. [12] The M: F ratio of 5.15: 1; in our study is similar to that reported earlier in Madina by Rabi et al., who found an M: F ratio of 5.2:1 [14] However, the M: F ratio found in our study is significantly less than the ratio of 10: 1; seen in Aseer [15] a mountainous region of the Kingdom with high risk of RTAs. Males are more frequently liable to be injured than females due to their increased outdoor activity and involvement in interpersonal violence. In addition, Saudi Arabian women are not permitted to drive by law which explains their lesser number.

The highest number (113) of patients was found in the age group between 16 – 30 years (57.36%) which included 100 males and 13 females. Our finding is in agreement with the earlier 5 year Madinah study of Rabi and Khateery [14] who found majority of patients with fracture of the Mandible in the group aged 21 to 30 years (33%) and concurs with studies with a similar observation. [7,16,17] This typical age group is considered to comprise of young adults and are often described as a risk population for occurrence of mandibular fractures. [7] Few studies also found the age group 16-35 years to be commonly involved in accidents and occurrence of fracture which is closer to our finding. [13,18,19] 140 patients in the present study were between 16 – 45 years and formed a significantly huge number (71%) of patients with trauma and fracture of mandible in concurrence with a study in Makkah. [10] This implies a need to target and motivate this vulnerable and ‘at risk’ age group towards safer driving.

44 patients (22.33%) in the group of 1 – 15 years had fracture of the mandible. Sakr et al., [20] quote a higher incidence of fracture in children in the first decade of age. 10 (5.07%) patients were between 46 – 60 years of age. Only one patient was seen in the age group of 61 – 75 years and two were above 76 years. A restricted sedentary life style may explain less RTA related trauma in elderly individuals.

Our finding of RTA as the main etiology of maxillofacial injuries with mandible fractures is in agreement with several studies done in developing countries including KSA and UAE. [9,10,21-23] Few others have found motorcycle accidents to be a major cause of mandible fractures. [24,25]

The very high frequency of RTA and related fracture of mandible is not surprising because, Saudi Arabia is ranked 23rd in the world on the list of countries having highest death rates in road accidents among high income states (accident to death ratio is 32:1 versus 283:1 in USA), and RTA is considered to be the country’s main cause of death for 16-30 years old males. Road injuries are reported to be the most serious in this country with an accident to injury ratio of 8:6, compared with the international ratio of 8:1.The rate of RTA caused by 4-wheeled vehicles in Saudi Arabia is the highest of all worldwide accidents. [3,26,27]

In this study a history of fall was given by 12 patients (6.09%) which is the second but a much less frequent cause than RTA for mandible fracture in Madinah. This is in agreement with Harshitha et al., [28] whereas in a Turkish study, falls were the main cause of mandible fracture. [29] In Madinah, falls from bicycles, motor cycles, desert bikes and falls from staircase or escalators in shopping malls were some of the reasons given.

Assault or Inter personal violence was reported in only 2.5% of patients in this study with fracture of the mandible. This is in total contrast with studies that have shown assault or IPV as the most common cause of maxillofacial injuries including mandibular fractures in many countries of the developed western world. [26,30-32] as well as in Australia and New Zealand. [33,34] Very high assault rates of 72.5% in Sydney, Australia and 74% in Manchester, United Kingdom have been documented by Rix and Asadi. [35,36] Compared to RTA in urban areas, assault is recognized as the main cause of Mandibular fractures in rural population. [4,33,37] Alcohol and drug consumption, Behavioural problems, Stress, Socioeconomic conditions, Political, Racial and Cultural provocations or domestic squabbles are several reasons cited for increased IPV or Assault across the globe. [38]

The conservative nature of Saudi society and family values, strict punitive laws for assault and fear of job loss in expatriates occasionally results in pre-hospital compromise between individuals and causes under-reporting of alleged assault at the time of hospital admission.

Ten bicyclists and four motor cyclists suffered fracture of the mandible due to direct trauma by falls from the bicycle or motor cycle. The males were mostly hurt by falling from the motor cycle while trying to perform ‘stunts’ or ‘drag racing’ on the roads whereas two female patients were injured during joy riding on a desert motorbike. Four of the patients with fracture of mandible were pedestrians and one worker sustained occupation tool related trauma.

In a study, the drivers’ knowledge regarding road traffic rules and risks did not match their behaviour and it was found that fatal and non-fatal injuries are significantly determined by speeding, particularly at daytime, and head-on collision to affect the magnitude of the accident. [38] Excessive speed, improper turning, traffic violations, tyre failure, fatigue with lack of sleep and hypoglycaemia were some causes attributed for the accidents. [39] However, driver error was found to be the main contributing factor in approximately two-thirds of all RTAs. [40]

Our finding is in agreement with a high frequency of condylar fractures found by Ahmed Jan et al., [11], in Jeddah, Saudi Arabia. Studies from other countries done by Bereket C, [29] Schön et al., [41] Matos et al., [42] and Van Beek [43] have also found condyle to be the most frequently affected site. While RTA was the main etiology of the condylar fractures in our study, fall and assault have been found to be most commonly associated with condylar fractures by others. [22,44,45] Few studies have reported the condyle as being the second most frequently fractured site location after the symphysis and parasymphysis areas. [14,46] Our finding differs from some regions of Saudi Arabia and other countries where the body of mandible was found to be the most common mandibular fracture site location. [14,16,24,47]

Kheirallah M and Almeshaly H [48] in an epidemiological analysis of mandibular fractures in KSA over 25 years from 1991-2016 found three studies from KSA, and eleven from other countries which had discussed the location of mandibular fractures. Their analysis reveals that condyle of the mandible was the most common fracture site not only in Jeddah but also cumulatively from the three studies in KSA. The second most common fracture site seen in their analysis were of the body and then the angle in KSA and the major etiology of facial fractures was due to road traffic accident. In contrast to their finding in studies from Saudi Arabia, the authors found the body of mandible to be the most common fracture site followed by fracture of condylar process in other countries, where the etiology also unlike in Saudi Arabia was commonly due to assault not RTA.

Several studies have reported Parasymphysis as the most affected site of fracture in the mandible. [12,24,25,28,30] Elgehani et al., [16] noted that the most common site of fracture was the Parasymphysis, followed by angle of the mandible. Few authors reveal the most common site of fracture being Parasymphysis followed by body, angle and condyle of the mandible. [35] Parasymphysis as the commonest site of fracture followed by that of condyle has also been reported. [44,49]

In our study Angle fracture was the second more frequent site of mandible fracture. Angle of the mandible as the most frequent site fractured has been reported in Riyadh [13,20] and other countries. [50]

Studies from different countries show wide variation in the location of the fracture site in the Mandible. Differences in regional and patient factors, etiology and mechanism of injury may be some of the contributing causes for the variation.

The most common combination of bilateral fractures in our study is condyle with parasymphysis in 18 patients. This is in agreement with a Turkish study. [34] A horizontally directed impact to the Parasymphysis is believed to cause a concentration of tensile strain at the condylar neck resulting in a condylar fracture. Our observation is contrary to Dongas and Hall [37] who reported Parasymphysis with angle and Ogundare et al., [21] who found body with angle as the most frequent mandibular fracture combination.

Conclusion

• Motor vehicle road traffic accident was the most common etiology of mandibular fractures in Madinah followed by fall and assault.

• Majority of the victims were Saudi nationals and in the role of vehicle drivers. Most of the patients were males with a M: F ratio of 5.15:1

• Highest number of patients was found in the age group of 16 – 30 years, recognizable as a risk group.

• Our study found the condylar region to be the most common anatomical site of mandible fractured followed by the body, angle and Parasymphysis.

• Most frequent combination of bilateral mandibular fractures was condyle with Parasymphysis. Bilateral same site fracture was seen more at the Angle

• The results of this retrospective study show similarity with some studies and differ with those of several others.

• There is an undisputed, urgent need in Saudi Arabia for road safety education and behaviour modification of drivers especially in the ‘at risk age group’ of 16 – 30 years. Relying solely on strict traffic rules and penalties will not address the basic contributing cause of reckless human attitude on the roads.

Conflict of Interest

All authors disclose that there was no conflict of interest.

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