DISCUSION

Factors relevant to mandibular fracture complications. A five-year experience

Factores relevantes en complicaciones de fracturas mandibulares. Relato de 5 años

José I. Iriarte Ortabe¹; Carmen Bosch Lozano²

¹Especialista en Estomatología, Cirugía Oral y Maxilofacial. Jefe del Servicio de Cirugía Oral y Maxilofacial, Hospital Son Dureta, Ib-Salut, Palma de Mallorca. España
²Especialista en Cirugía Oral y Maxilofacial. Médico Adjunto del Servicio de Cirugía Oral y Maxilofacial, Hospital Son Dureta, Ib-Salut, Palma de Mallorca. España

The authors report an observational, longitudinal, and putatively prospective review of the factors related to complications of mandibular fracture surgery over a 5-year period.

The involvement of 10 factors in the occurrence of postoperative complications is analyzed, including age, gender, occupational status, drug abuse, etiology of the injury, time to treatment, type of fracture, complication, and treatment.

The analysis of the material and methods did not clarify whether it was a prospective study. It was not known if a previous questionnaire was used. The authors apparently reviewed the patients’ medical records and recorded the data referring to the ten factors studied.

Of the 472 patients in the study, 11% (54 patients), almost all men (82%), experienced complications that required hospitalization and additional surgery in half of the cases.

The most frequent cause of jaw fractures is traffic accidents (Brasileiro et al.⁵, but the most relevant etiology in the series of complicated cases was assault (35%). Generally speaking, the factors depended largely on the geographic area studied. In areas of greater economic development, mandibular fractures produced by assault were more frequent, with traffic accidents (bicycle, motorcycle, and automobile) passing to second place, as was observed in our study area.

The higher incidence of complications in groups at risk, such as immunocompromised patients, intravenous drug users, drug addicts (polydrug), and patients with poor personal hygiene and nutritional habits, is well documented. This was confirmed in the study group, in which there was a high rate of chronic alcohol use (48% of patients with complications) and substance abuse (18%), which was very similar to the data collected by Passeri et al.⁶

It is often thought that certain circumstances, such as delay in seeking medical care by patients (assault, drunkenness, substance abuse), influences the occurrence of complications.

On the other hand, it is not unusual that mandibular fractures cannot be treated early due to the presence of associated injuries, multiorgan damage, or other priority circumstances that affect the patient’s hemodynamic instability and delay the definitive treatment of the mandibular fracture.⁴

In the series studied by the authors, 70% of patients sought medical care in the 48 first hours after injury. Therefore, the occurrence of complications was not intimately related to delayed fracture treatment. This was also observed by Jason et al.,¹ and contradicts the opinion of Champy et al.² and Cawood,³ who recommend not delaying treatment more than 12 h or 24 h, respectively.

We agree with these and other authors that infection is the most frequent postoperative complication and the one most feared by surgeons. In addition, other "minor" complications usually are present at the start of treatment that can condition treatment failure: fixation plate exposure, malunion, pseudoarthrosis, and others (34% in this series).

The most frequent complication in this group was infection; 32 patients suffered infection, including almost 60% of the patients with postoperative complications.

The abuse of substances like alcohol is a factor that has been shown to be relevant to the occurrence of postoperative infection.⁷ In patients with chronic alcohol use, histologic evidence is found of reduced bone formation. This is supported by diminished serum calcitonin, a protein that is secreted by osteoblasts and is biochemical marker of bone formation.¹

The occurrence of infections in patients with daily substance abuse (parenteral or other) is common. These patients often suffer malnutrition and have a poor capacity to respond to infection.⁶ However, in HIV-positive patients it has been seen that if the CD4 count is normal, immunosuppression and postoperative infections are no more frequent than in the non-HIV population.⁷

Another factor that increases the incidence of postoperative infections in mandibular fracture surgery is the use of open reduction and internal fixation techniques, as opposed to closed reduction techniques. However, open techniques have the advantage of better stabilizing the fracture line, which optimizes ossification with minimal mandibular immobilization.

The postoperative infection rate using open reduction techniques ranges from 5% to 32% depending on the author.⁸

Likewise, we agree with the authors that factors like the severity of injury and type of fracture influence the development of postoperative complications like infection or impaired consolidation because the treatment is more complex.

The collection of such a large group of patients with facial fractures offers an opportunity to thoroughly verify the influence of concurrent epidemiologic factors.

However, we think that the design of this retrospective study is inadequate. The data were not managed epidemiologically or analyzed statistically to identify significant associations between the factors studied and the occurrence of complications.

No mention is made of the fracture location, which is important because it is known that mandibular angle fractures have more complications.

Unfortunately, the authors did not include the medical and surgical treatment protocol of the patients studied and we do not know what antibiotic coverage was used, the surgical technique (closed or open, intraoral or extraoral), the presence or absence of postoperative maxillomandibular fixation, surgical time, or the qualifications of the surgeon. It is very difficult to assess the contribution of these factors to the occurrence of postoperative complications in these circumstances.

Although the authors indicate that "postoperative complications were the focus point of this study", the analysis of these complications seems insufficient and overly superficial. Complications related to the surgical approach (fixation plate exposure and facial nerve paralysis, permanent?) are described but no information is given on their magnitude with respect to the treatment group. A percentage of patients had two complications, but no information is given on the specific complications, although it would be interesting to examine associations.

The criteria for determining the presence of fracture site infection are not defined (e.g., inflammation, pain, suppuration with or without drainage, and signs of nonunion or malunion with pain and inflammation).

In conclusion, the authors present a 5-year retrospective review of the factors contributing to complications in the surgical treatment of mandibular fractures that confirms the findings of the literature. It would benefit from more epidemiologic analysis to determine the significance of associations between the factors studied and the occurrence of complications.

References

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