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Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo
EDUARDO VASQUEZ DA FONSECA 1 | DANIEL FALBO MARTINS 1 | RENATO CARDOSO 1 | MANOEL ROQUE PARAÍSO SANTOS FILHO 1 | LUCIANO HENRIQUE FERREIRA LIMA 2
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ABSTRACT
Introduction: The mandibular region presents a high rate of involvement in facial trauma, generating functional and aesthetic damages. Objectives: The aim of this study is to outline the profile of patients with mandibular fractures treated at the Conjunto Hospitalar do Mandaqui, focusing on its etiology, age/sex ratio and anatomic region affected. Method: An epidemiological survey of patients diagnosed with mandibular fractures attended at the Conjunto Hospitalar do Mandaqui from January 2011 to January 2019 through the analysis of medical records and imaging tests. Results: From the 434 patients with maxillofacial trauma treated during the study period, 353 (81%) presented mandibular fracture with characteristics for inclusion in the study. The age group ranged from 2 to 78 years, male/female ratio was approximately 8:2. The main etiologies were traffic accidents (36.64%), aggressions (33.99%) and falls (15.58%). The most affected anatomic regions were the mandibular angle (26.72%), the mandibular body (24.22%) and the mandibular head (17.12%), and the coronoid process region was the least affected (0.42%). Conclusion: The prevalence and causes of mandibular fractures reflect the pattern of facial trauma of a population, and may help in the development of preventive measures, mainly to improve public policies for traffic safety and crime control.
Keywords: Epidemiology. Mandibular fractures. Traumatology.
1 Conjunto Hospitalar do Mandaqui, Departamento de Cirurgia Bucomaxilofacial (São Paulo/
SP, Brazil). 2 Pontifícia Universidade Católica de Minas Gerais, Departamento de Odontologia (Belo Horizonte/MG, Brazil).
How to cite: Fonseca EV, Martins DF, Cardoso R, Santos Filho MRP, Lima LHF. Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9. DOI: https://doi.org/10.14436/2358-2782.5.3.034-039.oar
Submitted: February 07, 2019 - Revised and accepted: August 09, 2019
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
Contact address: Manoel Roque Paraíso Santos Filho Rua Butantã, 408, ap. 805, Pinheiros – São Paulo/SP CEP: 05.424-000 – E-mail: manoelctbmf@gmail.com
INTRODUCTION
The face is a region of great importance for social life. It is used to show emotions, communicate, and it is where most of our sensory organs are located. Thus, injuries that affect the maxillofacial complex, besides the physical and functional sequels, also affect the personal and social relationships of the individual, and therefore are stigmatizing traumas. 1
Mandibular fractures are the most common among facial fractures. They may occur in isolation or in combination with other facial injuries. The pattern of mandibular fractures is established in the literature of several countries and these statistics vary from one country to another, thus being evident that some of the variations can be assigned to social, cultural and environmental factors. 2,3,4
Most epidemiological studies put the mandible as the facial bone most affected by fractures, 5,6,7 corresponding to 36% to 70% of facial bone fractures; 8 others consider to be the second most frequently fractured body site, behind the fractures of nasal bones. 9,10
Despite having a dense and sturdy bone structure, the reason for this high prevalence may result from the fact that the mandible is projected in the lower facial third, making it vulnerable to the direct action of mechanical forces, besides its open arch shape, 5,8 in addition to noticeable process of atrophy after tooth loss. 8,9
The treatment of complex maxillofacial fractures remains a challenge for maxillofacial surgeons, requiring skill and a high level of expertise. Such epidemiological information can also be used to guide the future financing of public health programs for prevention. 11
For that purpose, researchers 12 have conducted several studies on population groups from all continents, all with the common objective to attempt to elucidate the nature of mandibular fractures.
The incidence of maxillofacial trauma varies according to the geographical location where the sample was collected, distribution and socioeconomic trends in the population studied, as well as the traffic laws and seasonal variations. 1
METHODS
The study retrospectively evaluated the medical records of all trauma patients treated at the Oral and Maxillofacial Surgery and Traumatology residency program at the Conjunto Hospitalar do Mandaqui (CHM).
The study was approved by the Institutional Review Board of Conjunto Hospitalar do Mandaqui, Brazil (CAAE No. 04664918.500005551), with due consent of all involved organizations. Among the total of 434 patients with maxillofacial trauma, 353 were collected in a specific clinical form.
The data (etiology, age, gender, topography) were collected from the medical records of patients in the period from January 01 2011 to January 01 2019. These data were entered into the trauma survey form. The collected data were expressed in tables and graphs (Microsoft Excel-2010) and then analyzed.
The literature review included the following health databases: MEDLINE, LILACS, SciELO and BBO.
The keywords used were: traumatology, epidemiology and mandibular fractures.
The study was conducted at the Complexo Hospitalar do Mandaqui, which is a general teaching hospital at the tertiary level, being reference to trauma patients in the Brazilian Public Health System (SUS).
Population and sample
The study sample consisted of records of patients with mandibular fractures in the period January 01 2011 to January 01 2019.
Inclusion criteria
» Patients diagnosed with mandibular fractures treated at SUS. » Patients’ records filled properly. » Acceptance of proposed therapy. » Patients who agreed to participate and signed the informed consent form.
Exclusion criteria
» Incomplete patient records. » Non-acceptance of the proposed therapy. » Refusal to participate. » Patients treated outside the period proposed in this study.
Data analysis
Data were collected to fill the pre-established protocol with the information considered relevant for the study and are presented as graphs.
RESULTS
Concerning gender, it was observed that 298 (84.42%) patients in the sample were males (Fig. 1).
Concerning the age group, the most prevalent was between 21 to 30 years, including 121 (34.28%) patients, followed by the age group between 11 and 20 years of age, represented by 83 (23.51%) patients ( Fig. 2), and a minor involvement associated with the age between 0 and 10, by 8 (2.26%) patients, followed by the age group over 60 years old, which was formed by a sample of 14 (3.97%) patients.
Regarding etiology, the most frequent report was car accidents with 129 (36.54%) patients, followed by physical aggression with 120 (33.99%) patients and 55 falls (15.58%). The least significant etiological factor was work accident, represented by 10 (2.83%) patients. There were 8 (2.27%) patients with other causes (pathological fractures, following third molar extraction, etc.) (Fig. 3).
Concerning the affected site, it was observed that 128 (26.72%) patients had fracture on the angle region, 116 (24.22%) on the mandibular body and 82 (17.12%) on the condyle. Among the affected sites in the mandibular region, fracture at the coronoid process region was only found in 2 (0.42%) patients (Fig. 4).
GENDER
MALE FEMALE
Figure 1: Percentage distribution of patients according to gender.
AGE RANGE
0-10 YEARS 11-20 YEARS 21-30 YEARS 31-40 YEARS
41-50 YEARS 51-60 YEARS MORE THAN 60 YEARS
Figure 2: Percentage distribution of patients by age.
ETIOLOGY
TRAFFIC ACCIDENT PHYSICAL AGRESSION FALLS SPORTS ACCIDENTS
WORD ACCIDENTS CUNSHOT
WOUND OTHER CASES
TOPOGRAPHY
Figure 3: Percentage distribution of patients concerning the etiology.
Symphysis Parasymphysis Body
Angle Branch Coronoid precess Mandibular condyle
Figure 4: Percentage distribution of patients by site involved.
DISCUSSION
Trauma is a major public health problem in all countries, regardless of socioeconomic development, and is the third leading cause of mortality in the world, preceded only by cancer and cardiovascular diseases. 13
The mandible is the only mobile bone in the face and is of paramount importance for functional activities as mastication, speech, swallowing and maintenance of dental occlusion, besides contributing to facial esthetics. Despite its high density, the mandible is prone to fractures, since it is an open arch, located at the lower facial region, related to hyperextensive and hyperflexive mechanisms of the head in car accidents and atrophy with age. 4 Mandibular fractures account for most fractures in the facial skeleton and may be related to social, cultural, economic and environmental factors. 13,14,15
The results of this study of patients with mandibular fractures who were treated at the Complexo Hospitalar do Mandaqui, SP, largely agree with the literature. Regarding the variable gender, the male to female ratio was 8: 2, similar to data in the literature, in which this ratio ranges from 3:1 to 5:1, 11 since males are more exposed to the etiological factors associated with trauma. The study of Mayrink et al. 15 used a sample quantitatively similar to that employed in this study and obtained a similar male to female ratio. In regions where females have less social participation, such as the Middle East, this proportion reaches up to 11:1; 4 however, some studies have reported an increased number of females with this fracture pattern, due to the greater participation of females in activities outside home, physical activities, car driving and increased urban violence. 13 With respect to age, the literature indicates the age group of 21-30 years as the most affected by this trauma, which is in accordance with this study and can be justified by being an economically active age range, thus more susceptible. 11,12,16 The elderly and children are little affected because they are most of the time in their homes and accompanied by caregivers. 13
According to some authors, 7,14,17 the mandibular angle is the most affected anatomical region, which confirms the findings presented in this epidemiological survey. However, other authors report the mandibular body, 10,18 symphysis/parasymphysis 9,11 and condyle. 19 Therefore, the topography is not unanimous and varies across regions.
Many studies indicate car accidents as the leading cause of mandibular fractures, 12,13,16,20 since Brazil is in fifth place with regard to car accidents, being preceded by India, China, the United States and Russia, 15 which was restated and presented in this study as the main cause. Also, another fact pointed out by other authors and worth mentioning is that the constant increase of the national population, especially in large urban centers, associated with social inequality and current stress levels, which are related to increased physical aggression among people assuming an important role in the etiology of facial trauma, 11,21-24 observed in this survey as the second most common cause, with a slight difference from the first, as reported in the recent study of Mayrink et al. 15
Therefore, with the data obtained in this survey, it is possible, by the evaluation of etiological factors most related to trauma, to create policies or approaches to solve or reduce this problem, particularly with regard to the impact of car accidents and physical aggressions.
CONCLUSION
Mandibular fractures occur in people of all ages and genders, in a variety of social contexts. The etiology often reflects changes in facial trauma patterns over the years. It is assumed that such epidemiological surveys, as the present, are useful for government agents and health professionals involved in the planning of future prevention and treatment programs.
The analysis of results allowed to conclude that, in the observed sample: » The mean age ranged from 21 to 30 years. » The most affected gender was male, corresponding to 84.42% of the sample. » The most prevalent etiology was car accident. » The most affected anatomical region was the mandibular angle (26.72%).
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