Assessment of Patterns of Mandibular Condylar
Fractures: A Study
from Multan
Atiqur Rehman1Aeeza Malik2
Basil Khalid3Sharina Naz4 Malik Saleem Shaukat5 Razia
Aftab6
2-5. Department
of Community Dentistry2/Oral Pathology3/Operative
Dentistry4/Science of Dental Materials,5Multan Medical
& Dental College, Multan, Pakistan.
Correspondence to:
Dr. Aeeza Malik, Email:aeezamalik@gmail.com, ORCiD: 0000-0002-1095-5105
ABSTRACT
Objective: To assess the frequency of
patterns of mandibular condylar fractures at Nishtar Institute of Dentistry,
Multan.
Methods: Thisdescriptivecross-sectional studywas conducted at outpatient &
ward of the oral &maxillofacial surgery department ofNishter Institute of
Dentistry, Multan from September 2018 to February 2019.Patients aged20-50 years
with clinical and radiological diagnosis of mandibular condylar fracture within
last 7 days were consecutively enrolled. The pattern of mandibular condylar
fracture along with cause of fracture, site of fracture, and degree of
displacement of fracture were noted.
Results: Out of 90 patients, mean age of
the patients was 37.49 + 9.57 years.There were 70 (77.8%) males and 20 (22.2%)
were females. The mean duration of fracture was 1.61 + 1.15 days. RTA was the
cause among 45 (50%), fall in 17 (18.9%), FAI in 12 (13.3%), fight in 11
(12.2%) and sports in 5 (5.5%) patients.Intracapsular fractures of the condylar
head were found in 11 (12.2%), condylar neck fracture in 22 (24.4%), and
subcondylar fractures in 57 (63.3%) patients. Displaced fracture was noted in
73 (81.1%) of the patients. Of these 73 patients, ≤5 mm displacement was
observed in 59 (80.8%) and >5 mm in 14 (19.2%) patients.
Conclusion: Unilateral subcondylar fractures of
less than 5mm displacement were the most frequently assessed patterns of
mandibular condylar fractures with the predominant etiology of Road Traffic
Accidents.
Keywords:Mandibular fracture, Sub-condylar fracture,
Road traffic accident.
INTRODUCTION
Maxillofacial
trauma has been investigated worldwide because it affects a significant
proportion of trauma patients and can become a serious clinical problem due to
the complexity of this specific anatomical region.1Maxillofacial injuries
are also frequent in Pakistan, with a high incidence of facial fractures
reported in various combinations.2Mandible fractures are the most
common among facial fractures, occurring in up to 58% in isolation and almost
52% in combination with other facial fractures3, and the highest
prevalence of mandibular fractures is condylar fractures.4-8
The
mandibular condyle may be broken by direct and indirect trauma, and the
displacement shall be determined by the direction, degree, magnitude and point
of contact of the impact, as well as by the state of the dentition and the
occlusal location.7Condylar fractures may be subclassified on the
basis of anatomical fracture rates to extracapsular (condylar neck or
subcondylar neck) or intracapsular (condylar head) and on the basis of the
degree of displacement to undisplaced, deviated, displaced or dislocated.8
There are two approaches to treating
mandibular condylar fractures; one is a conservative approach with closed
reduction while the other is an open reduction with internal fixation. The
current direction of mandibular condylar fracture therapy is to conduct an
aggressive, open reduction as often as possible rather than a cautious, closed
reduction.4
Keeping in mind the frequent
occurrence of Maxillofacial injuries in Pakistan and the fact that Mandible
fractures are the most severe among facial fractures, it is very important to
understand the trends of injuries, their relative frequency and proper
management protocols for these fractures in order to avoid complications, as
this can lead to functional and esthetic problems such as facia. This research
was therefore intended toassess the frequency of patterns of mandibular
condylar fractures at Nishtar Institute of Dentistry, Multan.
METHODS
Thisdescriptivecross-sectional studywas conducted
at outpatient & ward of the Department of Oral & Maxillofacial Surgery,
Nishter Institute of Dentistry, Multan from September 2018 to February 2019. Ethical
approval was obtained from Nishtar Institute of Dentristry prior conducting of
the study. Study protocol and use of data for research was explained to
patients to get fully informed consent.
Patients
with mandibular condylar fractures of short duration (within 7 days) and
belonging to both genders ranging in age from 20 to 50 years diagnosed
clinically and radiographically as having condylar fracture were consecutively
enrolled. However, patients were excluded those who are edentulous and having
fractures due to an iatrogenic cause, malunioned and maltreated fractures and
pathological fractures [tumor, cyst].
Cause
of etiological factors like road traffic accident (RTA), fall, fight, firearm
injury (FAI), and sports were noted along with and type of condylar fracture
which was established on radiographic examination in all patients. In addition
to this, site of fracture and displacement was also noted.
Data
were entered and analyzed via Statistical Package for Social Sciences (SPSS)
Version 21. Descriptive statistics like mean and standard deviation were
explored for quantitative variables like age and duration of fracture whereas
frequency and percentages were computed for qualitative variables like gender,
etiological factors, site of fracture, anatomical levels, and displacement.
RESULTS
Of
90 patients, majority of the patients were males 70 (77.8%) whereas 20 (22.2%)
were females. The mean age of the patients was 37.49 + 9.57 years. The mean
duration of fracture was 1.61 + 1.15 days ranging from a minimum of 1 to a
maximum of 5 days. Fractures were found to be bilateral in 21 (23.3%) patients,
whereas it was unilateral among 69 (76.7%) patients. Among those with
unilateral fractures 38 (55.1%) were on the left site whereas 31 (44.9%) on the
right site.
The
comparison of various etiologies responsible for the fracture showed that RTA
was the cause among 45 (50%) of the patients, fall in 17 (18.9%), FAI in 12
(13.3%), fight in 11 (12.2%) and sports in 5 (5.5%). Most of the male patients
had history of RTA 45 (64.3%) whereas FAI injury was reported in majority of
the female patients 12 (60%). RTA was also found higher in patients with left
site of fracture 24 (63.2%), bilateral fracture 21 (100%), undisplaced fracture
17 (100%), and sub condylar anatomical levels 45 (78.9%). (Table 1)
Intracapsular
fractures of the condylar head were found in 11 (12.2%) of the patients,
condylar neck was fractured among 22 (24.4%), while subcondylar fractures were
found in 57 (63.3%) of the patients. A higher frequency of sub condylar
fracture was found in males 57 (81.4%), patients having left site of fracture
36 (94.7%), bilateral fracture 21 (100%), and undisplacement 17 (100%).(Table
2)
Displaced
fracture was noted in 73 (81.1%) of the patients. Of these 73 patients with
displaced fractures, ≤5 mm displacement was observed in 59 (80.8%) and
>5 mm was observed in 14 (19.2%) patients. Displacement of >5 mm was
observed higher in female patients 14 (70%), right site of fracture 14 (45.2%),
intracapsular head 11 (100%), and sports as etiological factor 5 (100%). (Table
3)
|
Table 1: The comparison of
etiological factors with general characteristics of the patients (n=90) |
||||||||
|
Variables |
RTA
(n=45) |
Fall
(n=17) |
Fight
(n=11) |
FAI
(n=12) |
Sports
(n=5) |
|||
|
n
(%) |
n
(%) |
n
(%) |
n
(%) |
n
(%) |
||||
|
Gender |
||||||||
|
Males |
45
(64.3) |
17
(42.3) |
8
(11.4) |
0
(0) |
0
(0) |
|||
|
Females |
0
(0) |
0
(0) |
3
(15) |
12
(60) |
5
(25) |
|||
|
Site of Fracture |
||||||||
|
Left |
24
(63.2) |
14
(36.8) |
0
(0) |
0
(0) |
0
(0) |
|||
|
Right |
0
(0) |
3
(9.7) |
11
(35.5) |
12
(38.7) |
5
(16.1) |
|||
|
Bilateral |
21
(100) |
0
(0) |
0
(0) |
0
(0) |
0
(0) |
|||
|
Displacement |
||||||||
|
Un-displaced |
17
(100) |
0
(0) |
0
(0) |
0
(0) |
0
(0) |
|||
|
Displaced |
28
(38.4) |
17 (23.3) |
11
(15.1) |
12
(16.4) |
5
(6.8) |
|||
|
Anatomical Levels |
||||||||
|
Sub Condylar |
45
(78.9) |
12
(21.1) |
0
(0) |
0
(0) |
0
(0) |
|||
|
Condylar Neck |
0
(0) |
5
(22.7) |
11
(50) |
6
(27.3) |
0
(0) |
|||
|
Intracapsular Head |
0
(0) |
0
(0) |
0
(0) |
6
(54.5) |
5
(45.5) |
|||
|
RTA:
Road Traffic Accident, FAI: Foreign Body Aspiration |
||||||||
|
Table
2: Comparison of anatomical levels with general characteristics of the
patients (n=90) |
||||||||
|
Variables |
Anatomical
Levels |
|||||||
|
Sub
Condylar |
Condylar
Neck |
Intracapsular
Head |
||||||
|
n
(%) |
n
(%) |
n
(%) |
||||||
|
Gender |
||||||||
|
Males |
57
(81.4) |
13 (18.6) |
0
(0) |
|||||
|
Females |
0
(0) |
9
(45) |
11
(55) |
|||||
|
Site of Fracture |
||||||||
|
Left |
36
(94.7) |
2
(5.3) |
0
(0) |
|||||
|
Right |
0
(0) |
20
(64.5) |
11
(35.5) |
|||||
|
Bilateral |
21
(100) |
0
(0) |
0
(0) |
|||||
|
Displacement |
||||||||
|
Un-displaced |
17
(100) |
0
(0) |
0
(0) |
|||||
|
Displaced |
40
(54.8) |
22
(30.1) |
11
(15.1) |
|||||
|
RTA: Road Traffic Accident,
FAI: Foreign Body Aspiration |
||||||||
|
Table 3: Comparison of displaced
fracture with general characteristics of the patients (n=90) |
||
|
Displaced
Fracture |
||
|
Variables |
≤5
mm |
>5mm |
|
n
(%) |
n
(%) |
|
|
Gender |
||
|
Males |
53
(100) |
0
(0) |
|
Females |
6
(30) |
14
(70) |
|
Site of Fracture |
||
|
Left |
38
(100) |
0
(0) |
|
Right |
17
(54.8) |
14
(45.2) |
|
Bilateral |
4
(100) |
0
(0) |
|
Anatomical Levels |
||
|
Sub Condylar |
40
(100) |
0
(0) |
|
Condylar Neck |
19
(86.4) |
3
(13.6) |
|
Intracapsular Head |
0
(0) |
11
(100) |
|
Etiological Factors |
||
|
RTA |
28
(100) |
0
(0) |
|
Fall |
17
(100) |
0
(0) |
|
Fight |
11
(100) |
0
(0) |
|
FAI |
3
(25) |
9
(75) |
|
Sports |
0
(0) |
5
(100) |
|
RTA: Road Traffic Accident, FAI:
Foreign Body Aspiration |
||
DISCUSSION
This
study was conducted to determine the frequency of mandibular condylar fracture patterns.
Because males predominated in this study (77.8%), most of the etiologies
responsible for mandibular condylar fractures, including fighting, weapon
injury, aggression and sports, were primarily present in males.5A
male predominance in patients with mandibular condylar fractures has been
identified in other studies, such as Marker9 and Zaccharides4,
in which a male-to-female ratio of 2:1 and 3:1 was found.
In
the current study, the mean duration of fracture was 1.61 + 1.15 days,
reflecting the recent history of mandible injury in cases of fractures in this
study. The majority of fractures were unilateral, with a small number of
left-site fractures. It is in line with previous studies, which have indicated
more left-site unilateral mandible fractures.10,11,13Among all these
patients, whether bilateral or unilateral, the proportion of males and females
remained almost identical to that of the overall gender distribution in the
study population. This result is consistent with results from many other
studies.10,12-14In the Zaccharides4 report, males
accounted for 78.3 percent, while females accounted for 21.7 percent of the
patient population. There was also a similar distribution of the fracture hand,
with 26.3 percent bilateral fractures, 47 percent on the right and 53 percent
on the left.
Among
the etiological factors responsible for the fracture of the mandibular condyle,
it was found that the road traffic accident (RTA) was the most frequent cause
and was responsible for the fracture in half of the cases. The next most common
cause of fracture found in our study population was RTA, followed by fall,
firearm injury, sport, and fighting. RTA has also been stated to be the most
common cause of mandibular fracture in other studies.4 Zaccharides4
recorded that RTA was the responsible cause of 466 mandibular condyle fractures
in more than 55% of patients. The cumulative percentage of fighting and firearm
injury is higher in our sample, which may represent higher baseline
psychosocial instability in our society, resulting in higher crime rates and
increased abuse. However, this is an incidental finding and is not conclusive.
It needs further evaluation as our study was not designed to reflect on this
aspect.
Literature
suggests that most fractures are of a displaced form relative to an undisplaced
type.14-18Whereas, the majority of the fractures displaced had a
displacement of less than 5 mm. A study of 466 fractures of Zaccharides4 found
that 68% of patients had displaced fractures compared to 19% of cases with
undisplaced fractures, while an additional 12.67 percent of patients had
deviated fractures. Such estimates are consistent with our results in the
report. We had deviated fractures in the displacement > 5 mm category
because of the simplicity of the x-ray analysis and to prevent error bias.
Taking
into account the anatomical level of fracture, the mainstream of the related
studies14, 16-21 supports the results of the current study that the
majority of fractures occurred at subcondylar level, whereas condylar head
fractures were the least frequently found in the intracapsular region.
Zaccharides recorded that 62.23 percent of the fractures were subcondylar and
subcondylar.4
The
results of the study could be highlighted in the light of the limitation that
this study was merely a descriptive epidemiological study and that the sample
size of the research was also small. Further large-scale systematic studies are
suggested to exclude the findings of this study.
CONCLUSION
Unilateral
subcondylar fractures of less than 5mm displacement were the most frequently
assessed patterns of mandibular condylar fractures with the predominant
etiology of Road Traffic Accidents.
ETHICAL APPROVAL
The
protocol for this study was approved by the ethical review committee of Nishtar
Institute of Dentistry Multan.
AUTHORS CONTRIBUTION: AR, AM & BK substantially
contributed to the conception and design of the study. SN, MSM and RA worked in
acquisition, analysis and interpretation of the data. Revised critically for
intellectual content and gave final approval.
CONFLICT
OF INTEREST
There
is no conflict of interest that may profit or lose through the publication of
this paper.
ACKNOWLEDMENTS
Hearful
thanks to all the study participants and the examination team.
FUNDING: None
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