|Year : 2016 | Volume
| Issue : 2 | Page : 36-42
Changing pattern in the treatment of mandibular fractures in North-Western Nigeria
Adebayo Aremu Ibikunle1, Abdurrazaq Olanrewaju Taiwo1, Ramat Oyebunmi Braimah1, Olalekan Micah Gbotolorun2
1 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||9-Aug-2017|
Adebayo Aremu Ibikunle
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, PMB 12003, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Maxillofacial fractures constitute a significant proportion of fractures seen at tertiary hospitals. Management of maxillofacial fractures is challenging and often associated with reduced quality of life among patients if not properly managed. This study was designed to analyze the trend in management of maxillofacial fractures at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest Nigeria between 2011 and 2016.
Materials and Methods: Data on the sociodemographic characteristics, etiology, type of fracture, and treatment done were retrieved. Data analysis was done with SPSS and comparisons were made using Chi-square and t-test. Statistical significance was set at P < 0.05.
Results: A total of 341 fracture sites were observed in 201 patients, the majority were males giving a male to female ratio of 6.2:1. The overall modal age group at presentation was the 21–30 year age group accounting for 78 (36.3%) of all cases seen. Road traffic accident (RTA) was the principal etiological factor accounting for 137 (63.7%) of the fracture cases seen. The mandibular body and dentoalveolar sites were the most frequently occurring fracture sites on the mandible accounting for 69 (20.2%) and 42 (12.3%) of all fractures. A comparison of the etiological factors among groups of patients based on the year of presentation and gender was statistically significant (P = 0.02). A comparison of the mode of treatment (open reduction and internal fixation [ORIF] or closed reduction) among patients based on the year of treatment was statistically significant (P < 0.001).
Conclusion: RTA remains the foremost cause of maxillofacial fractures in our environment. Despite a variety of challenges, ORIF is gradually being embraced as a viable mode of treatment in our center.
Keywords: Maxillofacial fracture, open reduction and internal fixation, trauma
|How to cite this article:|
Ibikunle AA, Taiwo AO, Braimah RO, Gbotolorun OM. Changing pattern in the treatment of mandibular fractures in North-Western Nigeria. Afr J Trauma 2016;5:36-42
|How to cite this URL:|
Ibikunle AA, Taiwo AO, Braimah RO, Gbotolorun OM. Changing pattern in the treatment of mandibular fractures in North-Western Nigeria. Afr J Trauma [serial online] 2016 [cited 2017 Dec 16];5:36-42. Available from: http://www.afrjtrauma.com/text.asp?2016/5/2/36/212630
| Introduction|| |
Maxillofacial fractures constitute a significant proportion of injuries worldwide.,, The management of mandibular fractures has changed considerably over the years. Although treatment of maxillofacial fractures is varied, closed or open reduction is frequently used., Closed reduction is less invasive, has lower initial costs, requires less armamentarium, and does not require general anesthesia., However, closed reduction, especially those with maxillomandibular immobilization, is not without its drawbacks. This includes the fact that fracture reduction is not done under direct visualization; thus reduction may be inadequate leading to a myriad of possible complications., In addition, healing is by secondary intention and closed reduction may be contraindicated in certain conditions.,, The utilization of wire osteosynthesis and maxillomandibular fixation (MMF) has reduced considerably in developed countries, though it is still quite popular in developing countries.,,
This article aims to present the trend in management of maxillomandibular fractures and pattern of maxillomandibular fractures in a tertiary hospital in Northwestern Nigeria in the last 6 years.
| Materials and Methods|| |
The study setting was Usmanu Danfodiyo University Teaching Hospital (UDUTH), a 1000 bed regional referral hospital in Sokoto state, Northwestern Nigeria. The hospital serves the needs of the largely semi-urban/rural population of Sokoto state and neighboring geographical entities. Approval was for this study was obtained from the Research Committee of the Department of Dental and Maxillofacial Surgery, UDUTH. Records of patients, who were managed for maxillomandibular fractures between January 2010 and May 2016 were retrieved, and variables such as the age, sex, site, and treatment were retrieved.
Maxillomandibular fractures were diagnosed after thorough history taking, clinical examination, investigation, and interpretation of radiographs and/or computed tomography (CT) scans. Mandibular fractures were categorized in accordance with the Pogrel and Kaban classification into; condylar fractures, ramus fractures, angle fractures, body fractures, fractures of symphysis, and parasymphysis., Maxillary fractures were classified in accordance with the proposed classification by Renne Le Fort into Le Fort I, Le Fort II, and Le Fort III fractures., The etiology of injury was categorized into, assault, road traffic crash, falls, sport injuries, gunshot injuries, and miscellaneous.
Treatment of patients with neurologic deficits was delayed until they were certified fit for surgery. Treatment modalities included open reduction and internal fixation (ORIF) and closed reduction. Overall, closed reduction was done using varying combinations of arch bars, MMF, eyelet wires, direct dental wiring and suspension wires. ORIF was done using titanium plates such as microplates, mini-plates, stainless steel wires, and reconstruction plates [Figure 1] and [Figure 2]. Treatment of comminuted mandibular fractures and mandibular fractures complicated by bony avulsion were by open reduction; 2.7 mm reconstruction plate was used for fixation after 1.5 mm mini-plates were used for simplification. Closed reduction of maxillary fractures was by the use of eyelets/arch bars, MMF with or without internal suspension wires. Patients with incomplete or ambiguous records were excluded from the study. A comparison of the modes of treatment was done between patients seen from January 2011 to December 2013 and patients seen from January 2014 to July 2016.
|Figure 2: Open reduction and internal fixation of mandibular fracture with plates in situ|
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Data analysis was done with Statistical Package for Social Sciences (version 20, IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 341 fracture sites were observed in 215 patients, giving an average of 1.6 fracture sites per patient. The overall age range was from 3 to 65 years with a mean (±standard deviation [SD]) of 27.6 (12.5). There was an overall male predominance, giving a male, female ratio of 6.2:1. An analysis of the male, female ratio across the years shows a male preponderance in all the years reviewed [Table 1]. The overall modal age group at presentation was the 21–30 year age group accounting for 78 (36.3%) of all cases seen [Table 1]. The proportion of Maxillo-mandibular (MM) fractures accounted for by patients in the 21–30 year age group was highest in the year 2012, where it accounted for 15 (46.9%) of the patients seen in that year.
|Table 1: Mean age (±SD), Male/female ratio, fracture sites, mode of treatment, according to the years|
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Patients older than 60 years of age constituted the lowest proportion of patients who presented with maxillomandibular fractures (MMs).
The overall most common etiology for maxillomandibular fractures was road traffic accident (RTA) accounting for 137 (63.7%) of the fracture cases seen. Motor vehicle and motorbike related injuries represented 103 (47.9%) and 34 (15.8%) of all maxillomandibular fracture cases secondary to RTAs. The year on year proportion of MMs caused by RTAs was lowest in the years 2013 and 2014; it rose to almost parallel observed proportions seen in 2011 and 2012 by the year 2016 [Figure 3]. A comparison of the etiology of MMs across the years under study revealed a statistically significant difference in proportions (P = 0.02). Interestingly, the animal attack was the etiological factor in two patients, both of which were in the year 2015. Motorbike related RTAs (MBRTA) was the most frequent cause of MMs in the years 2011 and 2012, being the etiological factor in at least 40% of MMs seen in those years [Figure 3]. Fall from height was the most frequent cause of MMs among patients in the first decade of life [Table 2]. A comparison of the etiological factors among patients in the different age groups showed a statistically significant difference (P = 0.001). Moreover, a comparison of the etiological factors between the male and female genders revealed a statistically significant difference (P = 0.004)[Figure 4].
MMs were diagnosed by a combination of clinical and radiographic investigations. Plain radiographs and orthopantomograms were the most commonly used radiographic investigations, although, CT scans with three-dimensional reconstruction were used in 31 (16.6%) of cases [Figure 5]. Most of the patients who had CT scans were seen in the years 2015 and 2016 [Figure 5].
|Figure 5: The frequency of utilization of different types of radiographic investigations per year|
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A total of 341 fracture sites were recorded [Table 1]. In general, fractures occurred more often on the left side 196 (57.5%), while fractures on the right side accounted for 145 (42.5%) of the identified fracture sites [Figure 6]. This trend held true for all the years under review. Symphyseal fractures were diagnosed in 19 cases. The mandible was the most commonly fractured bone representing 140 (74.9%) of all fractures [Figure 7]. This drift was observed in the isolated analysis of data for each year. Isolated mandibular fractures accounted for 109 (54.2%) of all fracture cases, constituting the most frequently affected site in isolation. The mandibular body and dentoalveolar sites were the most frequently occurring fracture sites on the mandible accounting for 69 (20.2%) and 42 (12.3%) of all fractures. The foregoing was true in individual analysis of data for each year except the year 2015, where mandibular angle fracture was the most frequent fracture site observed 16 (26.2%).
|Figure 6: The distribution of fracture sites based on the side affected (right or left)|
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Closed reduction was used in 147 (73.1%), ORIF was utilized in 34 (16.9%) of the cases, while 20 patients declined surgical intervention [Figure 8]. Mini-plates were utilized in all cases where ORIF was done except seven cases, where wire osteosynthesis was used. One patient had ORIF in each of the years 2013 and 2014 [Figure 8]. However, by the years 2015 and 2016, over 30% of the patients seen in each year had ORIF [Figure 8]. A comparison of the mode of treatment among patients based on the year when treatment was done was statistically significant (P < 0.001).
|Figure 8: Depicts the proportions of the mode of treatment for each year|
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| Discussion|| |
Maxillomandibular fractures (MMs) have tremendous effect on patients' quality of life and may result in debilitating complications., The volume of maxillofacial fractures has risen with increasing industrialization and higher speed of transportation.,, It has been established that the pattern and characteristics of MMs vary considerably from one region to the other., Furthermore, the modes of management also vary considerably depending on diverse factors.,,, The mainstay of MMs management was closed reduction; however, this has since evolved into ORIF in more recent years.,
An average of 1.7 maxillomandibular fractures was observed per patient; this is appreciably higher than reports by Abdullah et al. who in a review of 200 patients with maxillofacial fractures respectively reported an average of 1.06 fractures per patients. However, it is comparable to the observation of Gali et al. who reported an average of 1.36 maxillofacial fractures per patient. An average of 34 MMs cases was seen per annum in this study; this is lower than reports from a previous Nigerian study where an average of 44 cases was reported per annum over a 10-year study period.
An age range of 3–65 years with a mean (±SD) of 27.6 (12.5) years was observed in this study, this is similar to other reports in the literature., Similar to other reports, the third decade of life was the modal decade of presentation., However, it contrasts with the report of Alves et al. who reported the fourth decade of life as the modal decade of presentation in their study.
The mean age seen in this study is comparable to the reports by Ulusoy et al. who reported a mean (±SD) of 26.04 (±14.88) years. However, it contrasts with the report by Alves et al. who observed a mean age of 45 years. The age range of patients observed in this study is similar to other reports., However, it is discordant with the report by Motamedi et al. who reported a maximum age of 112 in their study. This dissonance in observed data may be related to the relatively low life expectancy in this geographical region which is put at 50 and 52 years for males and females, respectively.
The preponderance of males over females in this study is analogous to existing reports in the literature.,,, However, the observed male/female ratio is much higher than reports from Europe but comparable to those from the Middle East.,, This observation may be attributed to the higher chances of male involvement in risky behavior. In addition, cultural and religious practices in Northern Nigeria, where this study was done, align toward patriarchy. Hence, the females are more likely to be homemakers.,,
RTA which consists of motor vehicle accidents (MVA) and MBRTA were the major cause of MMs in this series. This is in consonance with other studies.,, However, MVA accounted for comparatively lower proportions of MMs in the years 2013 and 2014, which was found to be statistically significant. MBRTA was the major cause of MMs among patients in some of the years under review. This highlights the rising profile of motorbikes as a means of public transportation in this region., Notably, safety measures such as the use of helmets and other protective wears are often not complied with; also motorbike overloading is common because of the drive to maximize profit by the riders., Intracity transportation in our region is mainly by motorbike.,
Assault, especially domestic violence-related assault may have been under-reported in this study, because of family pressure on victims. Victims are often prevailed on to keep the details of such acts secret. Unsurprisingly, fall from height was most frequently a cause of MMs among children; this is similar to reports in the literature. Young age has been identified as a risk factor for falls and fall-related injuries.
A statistically significant difference was observed in a comparison of etiological factors of MMs between males and females. This is akin to reports in the literature. This may be due to the difference in lifestyles between the genders. MMs were diagnosed by a combination of clinical examination and radiographic investigations. CT scans are particularly useful in the diagnosis and treatment planning for mid-facial fractures because of the relatively thin bones; indeed, plain radiographs have lower specificity and sensitivity than the CT scan especially in this region., The low frequency of utilization of advanced imaging techniques like CT scan was mainly due to the patients' inability to afford it. Most patients in our region of the country and indeed Nigeria as a whole make out-of-pocket payments for the healthcare needs.,
The mandible was the more frequently fractured bone. This is comparable to other reports in literature.,,, Although it contrasts with reports by Gassner et al. 2003 who, in an Austrian study reported maxillary fractures as being more common. Mandibular fractures are believed to be more common because of its prominent position., It also has a high chance of sustaining multiple fractures because of its tubular, horseshoe U-shape., The most commonly observed mandibular fracture site was the mandibular body. This is in agreement with previous reports in the literature., Although it contrasts with the observation of some authors.,,
Management of the fractures was mostly by closed reduction. Closed reduction is the mainstay of treating MMs in developing countries. However, this is beginning to change in our center, as evidenced by the significant increase in the number of cases treated by ORIF in the later years of this review. Affordability and theater time are the most encumbering factor against the emergence of ORIF as the mainstay of management of MMs in our center.
| Conclusion|| |
RTAs, comprising motor vehicle- and motorbike-related accidents was the major etiological factor elucidated. Hence, there is a need to improve road safety in Nigeria by all means possible. ORIF is the next frontier in the management of MFs in our environment, however, a number of factors including affordability, militate against its rapid development. These factors should be addressed to improve health-care delivery in our climes.
The authors wish to acknowledge the management and the records staff of the Usmanu Danfodiyo University Teaching Hospital, for their support especially in data retrieval for this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]