ARTÍCULO CLÍNICO

 

Factors relevant to mandibular fracture complications. A 5-year experience

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

 

 

 

E. Serena Gómez¹, L.A. Passeri²

1 Profesor del Área de Cirugía Bucal de la Facultad de Odontología de la Universidad Autónoma de Nuevo León, Monterrey, México.
2 Professor Titular de Cirurgia Buco-Maxilo-Facial, Disciplina de Cirurgia Plástica, Faculdade de Ciências Médicas - Unicamp Campinas - São Paulo-Brasil

Correspondence

 

 

 

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ABSTRACT

Objective: This study was made to determine the factors relevant to postoperative complications in patients treated for mandibular fracture.
Study design: The study was based on the medical records of patients seen in a five-year period at the Area of Bucco-Maxillo-Facial Surgery and Traumatology, School of Odontology of Piracicaba, UNICAMP, Brazil. The relevant patient information collected was: age, gender, occupation, substance abuse, etiology of injury, time to treatment, type of mandibular fracture, postoperative complications, and treatment of complications.
Results: A total of 472 patients had mandibular fractures, of which 54 (11.4%) developed a postoperative complication of treatment. In the group of patients with postoperative complications, men predominated with 44 patients and the mean age was 29.3 years. In this group, 35.2% of patients did not have an economically remunerated occupation and 33 (61%) reported substance abuse. Physical assault was the most common cause of mandibular fracture (35.1%). Multiple mandibular fractures were present in 34 patients (62.9%). Infection occurred in 32 patients (59.2%). Hospital treatment of the complication was necessary in 30 patients (55.5%).
Conclusions: Occupational status and time to treatment of mandibular fractures were not significant factors in the development of postoperative complications. However, the severity of the injury and type of fracture were influential, as well as substance abuse, which showed a strong relation with the occurrence of complications.

Key words: Complication; Mandibular fracture; Substance abuse; Infection.

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RESUMEN

Objetivo: Este estudio ayudará a comprender factores relevantes y su relación con complicaciones post-operatorias en pacientes con tratamiento de fracturas mandibulares.
Diseño de estudio: Para el estudio fueron obtenidos datos de pacientes atendidos en un periodo de cinco años por el Área de Cirugía y Traumatología Buco-Maxilofacial de la Facultad de Odontología de Piracicaba, UNICAMP, Brasil. Los datos relevantes de los pacientes en esta investigación fueron; edad, género, actividad económica, consumo de sustancias, etiología del trauma, demora de tratamiento de fractura, tipo de fractura mandibular, complicación post-operatoria y tratamiento a la complicación.
Resultados: Un total de 472 pacientes presentaron fracturas mandibulares, de los cuales 54 pacientes (11,4%) desarrollaron alguna complicación postoperatoria al tratamiento. En el grupo de pacientes con complicaciones postoperatorias, el género masculino predominó con 44 pacientes y la media de edad fue de 29,3 años de edad. En este grupo se presentaron sin actividad económica 35,2% de los pacientes y 33 (61%) relataron abuso en sustancias nocivas a la salud. La agresión física fue la causa mas común (35,1%). Fracturas mandibulares múltiples fueron relatadas en 34 pacientes (62,9%). Infección se presento en 32 pacientes (59,2%). Tratamiento hospitalario para las complicaciones fue necesario para 30 pacientes (55,5%).
Conclusiones: Actividad económica y demora en el tratamiento de fracturas mandibulares no fueron significantes en el desarrollo de complicaciones post-operatorias. Por otra parte, la severidad del trauma y el tipo de fractura, consideradamente pueden influir, así como el consumo de sustancias, que presentó una fuerte relación en la presencia de complicaciones.

Palabras clave: Complicación; Fractura mandibular; Sustancias; Infección.

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Introduction

Maxillofacial injuries have increased in recent years, possibly due to the accelerated rhythm of daily life.^1,2 The mandible is a prominent bone in the facial anatomy and, as the objective point of contact during physical assault, is the facial bone with the highest fracture rate according to some reports in the literature.^1-4 Among the most common causes of maxillofacial injury are physical assault, traffic accidents (automobiles, motorcycles, bicycles, and pedestrian), gunshot wounds, sporting accidents and falls, among others. Each situation is related to the diverse social, cultural and environmental factors of each region, which is why the etiology can differ depending on regional customs.

The basic principles of the treatment of mandibular fractures include: fracture reduction, restoration of dental occlusion, fixation, and the control of postoperative infections and/or complications.⁵

Factors like delayed treatment, lack of antibiotic administration, teeth in the fracture line, substance abuse (tobacco, alcohol, illicit drugs), type of fracture treatment (reduction and fixation), type of mandibular fracture (multiple or comminuted fractures), surgeon inexperience, systemic disease, and lack of patient cooperation with treatment are the factors most commonly reported in the literature as increasing vulnerability to postoperative complications in the treatment of mandibular fractures.^5-9 The presence of these factors can favor the occurrence of delayed fracture union, malunion, nonunion, pseudoarthrosis, osteomyelitis, fixation plate exposure (FPE) and, most frequently, infectious processes in the fracture region. All these complications have been reported postoperatively in the treatment of mandibular fractures.^4-9

Patients who present some type of postoperative complication in the treatment of mandibular fracture require more prolonged treatment and often another intervention.^6-8

 

Material and methods

The objective of this study was to determine the factors that can increase vulnerability to postoperative complications in the treatment of mandibular fractures. This study was made in a region of the state of São Paulo, Brazil that has an urban and rural population. In this study we reviewed all the medical records of the patients seen in a five-year period (April 1999 – March 2004) by the Area of Bucco-Maxillo-Facial Surgery and Traumatology of the School of Odontology of Piracicaba (CTBMFFOP, Brazilian acronym) – UNICAMP. The patients were seen at seven different Trauma level I hospitals in the study region and at the CTBMF-FOP area outpatient clinic.

The patients’ data were compiled by undergraduate and graduate students of the CTBMF-FOP area and filed chronologically. The data later were transferred to a database created with Microsoft Excel 2003.

The data and personal history of each patient used in the study were: age, gender, habits, occupation, time to treatment after injury, etiology, type of mandibular fracture, postoperative complications, and treatment of complications.

All the patients included in this study were informed previously about the importance of this information for the investigation and the voluntary nature of participation. Each patient signed an informed consent form for the use of his or her data for the research purposes of the study. Patients with incomplete data in the medical records and patients who refused to sign the consent form were excluded from the study.

 

Results

In a five-year period, 1,024 patients with facial fractures were seen; 472 (46%) of these patients had mandibular fracture. Of them, 54 patients (11.4%) had a postoperative complication after treatment (Table 1).

The group that developed postoperative complications consisted of 44 men (81.4%) and 10 women (18.6%). The youngest patient was an eight-year-old boy who had a bicycling accident and the oldest patient was 55 years old; the mean age of this study group was 29.3 years. Most of the patients in the group (64.8%, 35 patients) were employed and 35.2% had no remunerated occupation (12 unemployed, 3 under-age students, 2 housewives, and 2 retirees).

Of 472 patients with mandibular fracture, 228 (47.4%) recognized substance abuse and 33 (14.4%) of this subgroup had a postoperative complication. Of the 54 patients with complications, 33 (61%) reported substance abuse (Table 1) and 21 (39%) stated that they did not consume any substances harmful to health. Substance abuse included chronic alcohol use in 26 patients (48.1%), smoking in 25 patients (46.2%), non-intravenous drug use (marijuana, cocaine, crack, opioids, etc.) in 7 patients (12.9%), and intravenous drug use (heroin) in 3 patients (5.5%). Nineteen patients (35.1%) used two different substances of abuse and 7 patients used three or more substances of abuse.

Violence was the main etiologic cause in the study group (Table 1), with 19 assaults (35.1%), including 14 physical assaults and 5 gunshot wounds. The second most frequent cause in patients with postoperative complications of mandibular fracture was automobile accident in 12 patients (22.2%) and the third cause, bicycling accidents in 8 patients (14.8%). Seven patients had motorcycle accidents, 3 sport accidents, 2 pedestrian motor injuries, 2 patients fell, and 1 had a work accident. It is interesting to note that out of a total of 472 patients with mandibular fracture, 19 were due to assault with a firearm, 5 (26.1%) of which presented postoperative complications.

After injury, 24 patients (44.4%) went to the hospital within 24 hours to seek treatment and 14 patients (25.9%) went on the second day. More than 48 hours after the injury, 16 patients sought medical care; the patient who took longest to seek care was seen 18 days after the facial injury.

Of the patients in the group of mandibular fracture with complications, 34 (62.9%) had multiple or bilateral fractures and 20 (37.1%) had single fractures. Thirteen patients presented other facial fractures related to the mandibular fracture.

Postoperative complications were the focus of this study and the most frequent were infections in 32 patients (59.2%), followed by 13 (24%) malunions, 6 (11.1%) fixation plate exposures due to tissue dehiscence, 5 nonunions, 2 cases of paralysis of a branch of the facial nerve, and one patient with limitation of mouth opening due to displacement of a bone fragment in mandibular condyle fracture. Overall, 59 complications occurred in 54 patients; 5 patients had two complications. Four patients developed a second complication; all of these patients acknowledged the use of more than one substance of abuse.

Most of the patients who had complications received hospital care. Thirty patients (55.5%) had to be hospitalized for a second operation and 24 (44.5%) received outpatient treatment (Table 1).

 

Discussion

Fractures occur more frequently in the mandible than in any other facial bone. Several parameters may vary depending on the customs and socioeconomic development of each specific region. In our study men were predominant in the group of mandibular fractures and in the group of patients with postoperative complications. Most of the patients with complications were between the third and fourth decades of life, a finding similar to the results of Senel et al.,¹⁰ who found 81.6% of male patients with a mean age of 28.5 years in a three-year longitudinal study in patients with postoperative mandibular fracture complications.

Occupation was not a significant factor in relation to mandibular fracture complications in this study. However, other authors have reported that deficiencies in the patients’ lifestyle may be a significant factor in the development of complications. ^8,11

A significant number of patients who acknowledged substance abuse developed postoperative complications. Passeri et al.⁷ reported a postoperative complication rate of 18.5% in a study of 589 mandibular fractures in which 15.5% of the patients with chronic alcohol use and 19% of patients who used non-intravenous substances of abuse presented complications. The complication rate in this study was 30% in patients who used intravenous substances of abuse. The results of this investigation demonstrated an important relation between substance abuse and postoperative complications in mandibular fracture.

Chronic alcohol use was reported by a significant number of patients who had complications. Chronic alcohol use (60 g of ethanol a day) impairs the immune system, suppressing T-cell response and increasing susceptibility to bacterial colonization and, consequently, to infection. The tissue healing process also is impaired by alcohol abuse.¹² Manus y et al.,¹³ demonstrated that patients with excessive alcohol use have nutritional deficiencies that affect bone metabolism, although the results indicated that this degree of malnutrition affects the treatment of mandibular fractures only marginally. Alcohol-induced immune system impairment reverses after two weeks of abstinence and is completely normal after two months.¹⁴

Traffic accidents were the main cause of mandibular fracture, as has been reported by other authors, but physical assault was the most frequent cause in the group that developed postoperative complications. Biller et al.,⁸ in a study of mandibular fractures in 84 patients, found that all the patients who presented postoperative infection were victims of physical assault. Most of the patients who were gunshot wound victims presented postoperative complications, which is why we assume that the intensity of the injury is a factor in the development of complications, together with the type of fracture since more than half of the patients with a history of postoperative complications had multiple jaw fractures. The severity and etiology of the maxillofacial injury are factors that can contribute to abnormal union and difficult treatment of mandibular fractures according to Li et al.¹⁵

In contrast with patients who suffer traffic accidents, patients who are victims of physical assault, especially heavy alcohol users, do not always seek medical care according to the experience of Biller et al.,⁸ which was why patients did not seek care in the first 12 hours or 24 hours, as recommended by Champy et al¹⁶ and Cawood,¹⁷ respectively. Early care can significantly reduce the possibility of infection in the treatment of mandibular fractures with fixation plate exposure. However, other authors report that the time to treatment of mandibular fractures has no relative importance in postoperative complications, but does make surgical fracture reduction and fixation more difficult, which is why malposition can result.^6,8 Our results also showed that delaying treatment after the injury was not a significant factor for the development of postoperative complications, because a large number of patients treated after 24 hours did not present any complication. On the other hand, factors like substance abuse showed a strong relation to complications.

Of the diverse complications that can develop in the treatment of mandibular fractures, the most frequent were infections of the fracture region. This result is similar to the findings reported by various authors who have studied mandibular fractures, such as Brasileiro et al.,⁴ Passeri et al.,⁷ Biller et al.,⁸ Moreno y et al.,⁹ Senel et al.,¹⁰ Lamphier et al.¹¹ and James et al.¹⁸ among others. Another common complication of mandibular fracture treatment is malunion. Li et al,¹⁵ found 135 cases of malunion a 10-year retrospective study of mandibular fractures. They reported that 3.57% of these patients also experienced postoperative infection and none of these patients consumed substances such as alcohol or drugs, demonstrating again that substance abuse favors infectious processes.

Most postoperative complications have to be treated in a hospital setting and a second surgical intervention is sometimes required for proper treatment, thus increasing patient morbidity and the time and cost of treatment.

 

Conclusions

Factors such as the patient’s occupation and time to treatment did not have a significant relation with the development of postoperative complications in this study of mandibular fractures. However, the severity of the injury and type of fracture entailed treatment of a certain complexity and complications may have developed as a result of this circumstance. Substance abuse was strongly relation with the occurrence of complications due to the systemic alterations involved. Most of the patients who had complications were men between the third and fourth decades of life. Infection was the most frequent complication in the treatment of mandibular fractures and it can be related to other postoperative complications.

 

 

Correspondence:
Luis Augusto Passeri
Faculdade de Ciências Médicas - Unicamp
Campinas - São Paulo - Brasil
E-mail: passeri@fcm.unicamp.br

Recibido: 24.04.07
Aceptado: 28.01.09

 

References

1. Tanaka N, Tomitsuka K, Shionoya K, Kimijima Y, Tashiro T, Amagasa T. Aetiology of maxillofacial fracture. Br J Oral Maxillofac Surg 1994;32:19-23.        [ Links ]

2. Allan BP, Daly CG. Fractures of the mandible. A 35-year retrospective study. Int J Oral Maxillofac Surg 1990;19:268-71.        [ Links ]

3. Ellis E III, Moos KF, El-Attar A, Arbor A. Tem years of mandibular fractures: An analysis of 2,137 cases. Oral Surg 1985;59:120-9.        [ Links ]

4. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: A 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28-34.        [ Links ]

5. Joss U, Meyer U, Tkrotz T, Weingart D. Use of a mandibular fracture score to predict the development of complications. J Oral Maxillofacial Surg 1999;57:2-5.        [ Links ]

6. Mathog RH,Toma V, Clayman L, Wolf S. Nonunion of the mandible: Analysis of contributing factors. J Oral Maxillofac Surg 2000;58:746-52.        [ Links ]

7. Passeri LA, Ellis E III, Sinn DP. Relationship of Substance Abuse to Complications with Mandibular Fractures. J Oral Maxillofac Surg 1993;51:22-5.        [ Links ]

8. Biller JA, Pletcher SD, Goldberg AN, Murr AH. Complications and the time of repair of mandible fractures. Laryngoscope 2005;115 May:769-772.        [ Links ]

9. Moreno JC, Fernández A, Ortiz JA, Montalvo JJ. Complication rates associated with different treatments for mandibular fractures. J Oral Maxillofac Surg 2000; 58:273-80.        [ Links ]

10. Senel FC, Jessen GS, Melo MD, Obeid G. Infection following treatment of mandible fractures: the role of immunosupression and polysubstance abuse. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:38-42.        [ Links ]

11. Lamphier J, Zicardi V, Ruvo A, Janel M. Complications of mandibular Fractures in an Urban Teaching Center. J Oral Maxillofac Surg 2003;61:745-9.        [ Links ]

12. Sandler NA. Patients who abuse drugs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:12-4.        [ Links ]

13. Manus RCJr,Dodson TB, Miller EJJr, Perciaccante VJ. Nutritional Status od Sustance Abusers With Mandible Fractures. J Oral Maxillofac Surg 2000;58:153-7.        [ Links ]

14. Tonnesen H, Kehlet H. Preoperative alcoholism and postoperative morbidity. Br J Surg 1999;86:869-74.        [ Links ]

15. Li Z, Zhang W, Li ZB, Li JR. Abnormal Union of Mandinular Fractures: A review of 84 cases. J Oral Maxillofac Surg 2006;64:1225-31.        [ Links ]

16. Champy M, Lodde JP, Schmidt R, Jaegar JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg 1978;6:14-21.        [ Links ]

17. Cawood JL. Small Plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985;23: 77-91.        [ Links ]

18. James RB, Fredrickson C, Kent JN. Prospective study of mandibular fractures. J Oral Surgery 1981;39:275-81.        [ Links ]