- Email: [email protected]
Is a fractured mandible an emergency?
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
Is a fractured mandible an emergency? D. Hammond a,∗ , S. Parmar b , J. Whitty a , M. McPhillips a , R. Wain a a b
University of Central Lancashire, Harrington Building, Preston, PR1 2HE Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH
Accepted 4 November 2017 Available online 22 November 2017
Abstract We retrospectively audited the records of 708 patients who presented with the diagnosis of fractured mandible between January 2009 and July 2013 at the Queen Elizabeth Hospital, Birmingham. We assessed the different factors that may have altered their outcomes, and found that delay before definitive fixation caused no harm in either the short or the long term. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Fracture mandible theatre delay
Introduction When a patient presents with a fractured mandible there are various opinions about the length of time that should elapse between the injury and definitive fixation before outcome is compromised. Some of the published evidence advocates a maximum delay from time of injury of 12 hours,1,2 and some within 24 hours.3 Two studies have suggested that patients who have definitive fixation more than 72 hours after injury have worse outcomes than those who are treated sooner. There is also contradictory evidence that there is no difference in outcome in patients who have definitive surgery within the first 72 hours of injury and those who are operated on later.4 However Wagner et al5 suggested that there is a spike in complications on both days two and six after injury, which leads to the conclusion that days three and four are the optimal days for fixation. Given that 65% of maxillofacial surgery units in the United Kingdom have no dedicated trauma list,6 this increases the ∗
Corresponding author. E-mail addresses: [email protected] (D. Hammond), [email protected] (S. Parmar), [email protected] (J. Whitty), [email protected] (M. McPhillips), [email protected] (R. Wain).
burden on the provision of emergency theatre lists. This in turn increases the likelihood of such operations being done after 1700 hours, and therefore reduces the likelihood of a consultant operating.7 It has also been shown that 60% of maxillofacial patients on the emergency theatre list wait more than 12 hours, and 29% wait longer than 24 hours.7 Currently there is obviously a burden on the emergency theatre list, and no sound evidence to indicate the best time for definitive fixation of mandibular fractures or how long this optimal window lasts. It is also imperative to find out whether a patient with a fractured mandible requires emergency treatment or whether the operation can be delayed until an elective list. This may also relieve pressure on beds and reduce complaints about delays in getting to theatre. We aimed to review retrospectively whether there was an optimal time for fixation of a fractured mandible. We looked at morbidity to find out whether one period of time was associated with a reduced number of complications compared with another.
Method We organised a retrospective study using information from the records of 708 patients who presented with the diagnosis
https://doi.org/10.1016/j.bjoms.2017.11.003 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
40
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
Table 1 Correlation between time before operation and morbidity. Data are number (% of total).
Total no of cases Postoperative infection requiring antibiotics Removal of fixation required (plate and screws) Return to theatre Fibrous non-union/non-union Malocclusion recorded Overall complication rate
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square
p value
252 (35.6%) 11 17 12 2 26 68
388 (54.8%) 21 16 15 4 27 83
56 3 2 4 1 8 18
12 1 2 0 0 1 4
– 0.63 5.61 1.90 5.59 4.48 5.15
– 0.89 0.13 0.66 0.14 0.21 0.17
There were no significant differences among the complications. Table 2 Grade of primary surgeon operating. Data are number of patients.
Consultant Registrar SHO
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
p value
41 186 25
63 292 33
10 44 2
5 7 0
5.43 6.54 3.53
0.14 0.51 0.50
There were no significant differences among the grades of surgeon. Table 3 Unilateral or bilateral fracture. Data are number of patients.
Unilateral Bilateral
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi Squared value
p value
56 196
105 273
15 41
4 8
2.84 2.84
0.42 0.42
There were no significant differences between the sides.
of fractured mandible between January 2009 and July 2013 to the Queen Elizabeth Hospital, Birmingham. All casenotes and radiographs were reviewed and the following data were recorded: age, sex, whether the patient was admitted to the intensive care unit (ICU), and the number of days between injury and definitive repair. Patients were classified into four groups according to the time from the alleged incident until operative intervention (treated: within 24 hours, between 24 and 72 hours, 72 hours to a week, and longer than a week). The outcomes that we looked at in the notes were: if the patient had to return to theatre, and why; if the patient had a postoperative infection that required treatment with antibiotics; if the patient required removal of metalwork (plate) within the first year postoperatively; if the patient had a fibrous union/non-union (diagnosed clinically and radiographically); and if the patient had a malocclusion postoperatively. The following factors that may influence outcome were also assessed: the grade of the surgeon operating; whether the fracture was unilateral or bilateral; and the type of fixation used. We excluded: isolated condylar fractures; pathological fractures; patients who had had a previous fracture of the mandible; patients who were conservatively managed; patients under 18 years of age; revision operations of an existing current fracture of the mandible; and operations that required an external fixator. Notes were assessed for up to a year after the date of injury, as this was deemed the maximum period for follow
up. The significance of the differences among the various groups was analysed using the chi square test with the aid of IBM Statistics for Windows (version 20, IBM Corp, Armonk, NY, USA).
Results Of the 708 patients 662 (93.5%) were male and 46 (6.5%) female, and their mean (range) age was 28 (18–78) years. Table 1 shows the correlation between complications and time of operation, and that there were no significant differences in complication rates. Table 2 shows that there was no significant difference among the groups between the grade of the primary surgeon who did the operation. However, a consultant operated in nearly half of the cases not operated on for a week, compared with less than a quarter in the three other groups (0–24 hours, 24–72 hours, and 72 hours-one week). Table 3 shows that there was no significant difference in the proportion of unilateral or bilateral fractures within each of the groups. Table 4 shows that there were significant differences in the method of fixation between the various time groups. The proportion of cases that required both plating and intermaxillary fixation increased with the length of time from injury to theatre, and the use of a reconstruction plate increased in proportion from 10.8% in the 24–72 hours group to 25% in the over one week group.
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
41
Table 4 Method of fixation. Data are number of patients, and all differences are significant. Method
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
P value
Standard plate alone Reconstruction plate (>2.0 mm thick) alone Plating and intermaxillary fixation
191 32 29
306 42 40
28 13 15
3 3 6
37.3 8.45 27.4
<0.00001 0.04 <0.00001
Table 5 Delay of operation and whether the patient was admitted to ITU or a standard ward. Data are number of patients.
ITU Standard ward
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
p value
3 249
25 363
14 42
7 5
90.6 90.6
<0.00001 <0.00001
Table 6 Geographical distribution of patients. Postcode
No (%) of patients
West Midlands postcode prefix (B, DY, WS, CV, WV) Postcode outside West Midlands
632 (89.2) 76
The chi square test shows that there is a highly significant difference between the length of time between injury and theatre if a patient was admitted to intensive care compared with a standard ward (Table 5). Across all the results there were fewer complications after 72 hours, and this was associated with the smaller number of patients who waited so long for the procedure. Table 6 shows that 89% of patients had a postcode prefix that suggests that they are local to the Queen Elizabeth Hospital.
Discussion Instinctively it might be thought that the sooner that a fracture of the mandible is operated on, the fewer the complications are likely to be. The incidence of infection secondary to mandibular fractures has been reported to range between 0 and 30%,8 and Maloney et al,9 and Anderson and Alpert,10 described rates of infection between 4.4% and 16%, respectively. However, these papers are almost 25 years old, and there have been advancements in plating systems since their data were published. Though this is a retrospective study, it does include a large number of patients, and a relatively short period of time (5.5 years including follow up). Table 1 shows that the length of time from injury after which a mandible has definitive fixation results in no significant difference in any of the variables studied. The overall complication rate in each group of our study (range:21.4%–33.3%) is comparable with that reported by Seeman et al (29.5%).11 Katsarelis et al12 showed that a total of 405 of their patients (80%) were operated on by the end of the next working day. Our shortest time between admission and theatre was 75 minutes and the longest, 11 days, 20 hours, and 51 minutes
(median 22 hours 7 minutes). However the phrase “within the next working day” encompassed up to a 42-hour period. At the Queen Elizabeth Hospital there was no dedicated emergency operating list for Oral and Maxillofacial Surgery, which probably explains the delay to treatment. Tables 2 and 3 show that there were no significant differences in the grade of primary surgeon operating, or whether the injury was unilateral or bilateral, which suggests that these were not major factors in morbidity. Table 6 shows that 632 patients (89%) had postcodes that suggested that they were local to the Queen Elizabeth Hospital, and so would reattend there rather than go to a different hospital if they had a complication. It may be that our results are skewed by a maximum of 10%–11% if every person outside the West Midlands postcodes attended a different hospital with a complication. Table 4 shows that as the length of time between injury and theatre increased, the use of two methods of fixation increased. In the 0–24 hour group 29/252 (11.5%) had their fractures fixed with both a plating system and intermaxillary fixation, whereas half the group who waited more than a week did. This was significant, as was the use of a reconstruction plate, which shows an increase from 13% to 25% between the same groups. This may be related to the significant difference in the number in the group operated on during the 0–24 hour period who were admitted to the ICU (1.2%) compared with the 58.3% operated on after a week (Table 5). This suggests that the patients had more severe or multiple injuries, and had to be stabilised preoperatively. It also suggests (but is not conclusive) that the injury to the mandible may have been more serious and required either bimodal fixation (plates, screws, and intermaxillary fixation) or a reconstruction plate, for appropriate reduction and fixation of the injury. These 708 cases, and the duration of operating time required for the procedures, puts a considerable burden on the emergency operating theatres. Kalantzis et al7 showed that over a five-year period their maxillofacial emergency workload doubled, and that the mean delay also increased significantly. It was fractured mandibles that were most likely to be left until last. There had been no reduction in the delays in other emergency operating.
42
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
The question that needs to be asked is: does a fractured mandible need to be operated on during an emergency list, or can it be placed on a dedicated elective maxillofacial trauma list? This would reduce the number of bed nights/admission, and save money, as in 201213 the approximate cost of an acute surgical bed was £682/night. A good bridle wire,14 appropriate analgesia, and antibiotics taken orally can be used to temporise a fractured mandible before definitive fixation.
Conclusions The results of this retrospective study show that there is currently no definitive answer to the question of when is the most appropriate time to provide appropriate fixation for a fractured mandible. They suggest that neither the grade of surgeon, nor whether the injury is unilateral or bilateral, affects the complication rate. We hope that they may stimulate a prospective study that deals with “time to theatre after injury”, to provide better evidence and hopefully a definitive answer.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission No ethics approval was required. All data were anonymised.
References 1. Champy M, Pape H-D, Gerlach KL, et al. The Strasbourg miniplate osteosynthesis. In: Kruger E, Schilli W, editors. Oral and maxillofacial traumatology, Vol 2. Chicago: Quintessence; 1986. p. 19–43. 2. Prein J, editor. Manual of internal fixation in the craniofacial skeleton. New York: Springer; 1998. 3. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985;23:77–91. 4. Czerwinski M, Parker ML, Correa JA, et al. Effect of treatment delay on mandibular fracture infection rate. Plast Reconstr Surg 2008;122:881–5. 5. Wagner WF, Neal DC, Alpert B. Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 1979;37:97–100. 6. El-Maaytah M, Upile T, Newman L. Survey of maxillofacial ‘out of hours’ operating in the United Kingdom. Br J Oral Maxillofac Surg 2009;47:320–2. 7. Kalantzis A, Weisters M, Saeed NR. Delays in emergency oral and maxillofacial operations: 5 years later. Br J Oral Maxillofacial Surg 2012;50:141–3. 8. Moulton-Barrett R, Rubenstein AJ, Salzhauer MA, et al. Complications of mandibular fractures. Ann Plast Surg 1998;41:258–63. 9. Maloney PL, Welch TB, Doku MC. Early immobilization of mandibular fractures: a retrospective study. J Oral Maxillofac Surg 1991;49:698–702. 10. Anderson T, Alpert B. Experience with rigid fixation of mandibular fractures and immediate function. J Oral Maxillofac Surg 1992;50:555–61. 11. Seemann R, Schicho K, Wutzl A, et al. Complication rates in the operative treatment of mandibular angle fractures: a 10 year retrospective. J Oral Maxillofac Surg 2010;68:647–50. 12. Katsarelis H, Lees T, McLeod N. Mandibular fractures – towards a national standard for time to theatre – national audit by the BAOMS Trauma Specialist Interest Group. Br J Oral Maxillofac Surg 2016;54:796–800. 13. Reference costs 2012 to 2013 – Gov. UK. Available from URL: www.gov.uk/government/uploads/system/uploads/attachment data/file/261154/nhs reference costs 2012-13 acc.pdf Last accessed 3 November 2017. 14. Perry M, Holmes S, editors. Atlas of operative maxillofacial trauma surgery: primary repair of facial injuries. New York: Springer; 2014.
ScienceDirect British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
Is a fractured mandible an emergency? D. Hammond a,∗ , S. Parmar b , J. Whitty a , M. McPhillips a , R. Wain a a b
University of Central Lancashire, Harrington Building, Preston, PR1 2HE Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH
Accepted 4 November 2017 Available online 22 November 2017
Abstract We retrospectively audited the records of 708 patients who presented with the diagnosis of fractured mandible between January 2009 and July 2013 at the Queen Elizabeth Hospital, Birmingham. We assessed the different factors that may have altered their outcomes, and found that delay before definitive fixation caused no harm in either the short or the long term. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Fracture mandible theatre delay
Introduction When a patient presents with a fractured mandible there are various opinions about the length of time that should elapse between the injury and definitive fixation before outcome is compromised. Some of the published evidence advocates a maximum delay from time of injury of 12 hours,1,2 and some within 24 hours.3 Two studies have suggested that patients who have definitive fixation more than 72 hours after injury have worse outcomes than those who are treated sooner. There is also contradictory evidence that there is no difference in outcome in patients who have definitive surgery within the first 72 hours of injury and those who are operated on later.4 However Wagner et al5 suggested that there is a spike in complications on both days two and six after injury, which leads to the conclusion that days three and four are the optimal days for fixation. Given that 65% of maxillofacial surgery units in the United Kingdom have no dedicated trauma list,6 this increases the ∗
Corresponding author. E-mail addresses: [email protected] (D. Hammond), [email protected] (S. Parmar), [email protected] (J. Whitty), [email protected] (M. McPhillips), [email protected] (R. Wain).
burden on the provision of emergency theatre lists. This in turn increases the likelihood of such operations being done after 1700 hours, and therefore reduces the likelihood of a consultant operating.7 It has also been shown that 60% of maxillofacial patients on the emergency theatre list wait more than 12 hours, and 29% wait longer than 24 hours.7 Currently there is obviously a burden on the emergency theatre list, and no sound evidence to indicate the best time for definitive fixation of mandibular fractures or how long this optimal window lasts. It is also imperative to find out whether a patient with a fractured mandible requires emergency treatment or whether the operation can be delayed until an elective list. This may also relieve pressure on beds and reduce complaints about delays in getting to theatre. We aimed to review retrospectively whether there was an optimal time for fixation of a fractured mandible. We looked at morbidity to find out whether one period of time was associated with a reduced number of complications compared with another.
Method We organised a retrospective study using information from the records of 708 patients who presented with the diagnosis
https://doi.org/10.1016/j.bjoms.2017.11.003 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
40
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
Table 1 Correlation between time before operation and morbidity. Data are number (% of total).
Total no of cases Postoperative infection requiring antibiotics Removal of fixation required (plate and screws) Return to theatre Fibrous non-union/non-union Malocclusion recorded Overall complication rate
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square
p value
252 (35.6%) 11 17 12 2 26 68
388 (54.8%) 21 16 15 4 27 83
56 3 2 4 1 8 18
12 1 2 0 0 1 4
– 0.63 5.61 1.90 5.59 4.48 5.15
– 0.89 0.13 0.66 0.14 0.21 0.17
There were no significant differences among the complications. Table 2 Grade of primary surgeon operating. Data are number of patients.
Consultant Registrar SHO
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
p value
41 186 25
63 292 33
10 44 2
5 7 0
5.43 6.54 3.53
0.14 0.51 0.50
There were no significant differences among the grades of surgeon. Table 3 Unilateral or bilateral fracture. Data are number of patients.
Unilateral Bilateral
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi Squared value
p value
56 196
105 273
15 41
4 8
2.84 2.84
0.42 0.42
There were no significant differences between the sides.
of fractured mandible between January 2009 and July 2013 to the Queen Elizabeth Hospital, Birmingham. All casenotes and radiographs were reviewed and the following data were recorded: age, sex, whether the patient was admitted to the intensive care unit (ICU), and the number of days between injury and definitive repair. Patients were classified into four groups according to the time from the alleged incident until operative intervention (treated: within 24 hours, between 24 and 72 hours, 72 hours to a week, and longer than a week). The outcomes that we looked at in the notes were: if the patient had to return to theatre, and why; if the patient had a postoperative infection that required treatment with antibiotics; if the patient required removal of metalwork (plate) within the first year postoperatively; if the patient had a fibrous union/non-union (diagnosed clinically and radiographically); and if the patient had a malocclusion postoperatively. The following factors that may influence outcome were also assessed: the grade of the surgeon operating; whether the fracture was unilateral or bilateral; and the type of fixation used. We excluded: isolated condylar fractures; pathological fractures; patients who had had a previous fracture of the mandible; patients who were conservatively managed; patients under 18 years of age; revision operations of an existing current fracture of the mandible; and operations that required an external fixator. Notes were assessed for up to a year after the date of injury, as this was deemed the maximum period for follow
up. The significance of the differences among the various groups was analysed using the chi square test with the aid of IBM Statistics for Windows (version 20, IBM Corp, Armonk, NY, USA).
Results Of the 708 patients 662 (93.5%) were male and 46 (6.5%) female, and their mean (range) age was 28 (18–78) years. Table 1 shows the correlation between complications and time of operation, and that there were no significant differences in complication rates. Table 2 shows that there was no significant difference among the groups between the grade of the primary surgeon who did the operation. However, a consultant operated in nearly half of the cases not operated on for a week, compared with less than a quarter in the three other groups (0–24 hours, 24–72 hours, and 72 hours-one week). Table 3 shows that there was no significant difference in the proportion of unilateral or bilateral fractures within each of the groups. Table 4 shows that there were significant differences in the method of fixation between the various time groups. The proportion of cases that required both plating and intermaxillary fixation increased with the length of time from injury to theatre, and the use of a reconstruction plate increased in proportion from 10.8% in the 24–72 hours group to 25% in the over one week group.
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
41
Table 4 Method of fixation. Data are number of patients, and all differences are significant. Method
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
P value
Standard plate alone Reconstruction plate (>2.0 mm thick) alone Plating and intermaxillary fixation
191 32 29
306 42 40
28 13 15
3 3 6
37.3 8.45 27.4
<0.00001 0.04 <0.00001
Table 5 Delay of operation and whether the patient was admitted to ITU or a standard ward. Data are number of patients.
ITU Standard ward
0–24 hours
24–72 hours
72 hours–1 week
>1 week
Chi square value
p value
3 249
25 363
14 42
7 5
90.6 90.6
<0.00001 <0.00001
Table 6 Geographical distribution of patients. Postcode
No (%) of patients
West Midlands postcode prefix (B, DY, WS, CV, WV) Postcode outside West Midlands
632 (89.2) 76
The chi square test shows that there is a highly significant difference between the length of time between injury and theatre if a patient was admitted to intensive care compared with a standard ward (Table 5). Across all the results there were fewer complications after 72 hours, and this was associated with the smaller number of patients who waited so long for the procedure. Table 6 shows that 89% of patients had a postcode prefix that suggests that they are local to the Queen Elizabeth Hospital.
Discussion Instinctively it might be thought that the sooner that a fracture of the mandible is operated on, the fewer the complications are likely to be. The incidence of infection secondary to mandibular fractures has been reported to range between 0 and 30%,8 and Maloney et al,9 and Anderson and Alpert,10 described rates of infection between 4.4% and 16%, respectively. However, these papers are almost 25 years old, and there have been advancements in plating systems since their data were published. Though this is a retrospective study, it does include a large number of patients, and a relatively short period of time (5.5 years including follow up). Table 1 shows that the length of time from injury after which a mandible has definitive fixation results in no significant difference in any of the variables studied. The overall complication rate in each group of our study (range:21.4%–33.3%) is comparable with that reported by Seeman et al (29.5%).11 Katsarelis et al12 showed that a total of 405 of their patients (80%) were operated on by the end of the next working day. Our shortest time between admission and theatre was 75 minutes and the longest, 11 days, 20 hours, and 51 minutes
(median 22 hours 7 minutes). However the phrase “within the next working day” encompassed up to a 42-hour period. At the Queen Elizabeth Hospital there was no dedicated emergency operating list for Oral and Maxillofacial Surgery, which probably explains the delay to treatment. Tables 2 and 3 show that there were no significant differences in the grade of primary surgeon operating, or whether the injury was unilateral or bilateral, which suggests that these were not major factors in morbidity. Table 6 shows that 632 patients (89%) had postcodes that suggested that they were local to the Queen Elizabeth Hospital, and so would reattend there rather than go to a different hospital if they had a complication. It may be that our results are skewed by a maximum of 10%–11% if every person outside the West Midlands postcodes attended a different hospital with a complication. Table 4 shows that as the length of time between injury and theatre increased, the use of two methods of fixation increased. In the 0–24 hour group 29/252 (11.5%) had their fractures fixed with both a plating system and intermaxillary fixation, whereas half the group who waited more than a week did. This was significant, as was the use of a reconstruction plate, which shows an increase from 13% to 25% between the same groups. This may be related to the significant difference in the number in the group operated on during the 0–24 hour period who were admitted to the ICU (1.2%) compared with the 58.3% operated on after a week (Table 5). This suggests that the patients had more severe or multiple injuries, and had to be stabilised preoperatively. It also suggests (but is not conclusive) that the injury to the mandible may have been more serious and required either bimodal fixation (plates, screws, and intermaxillary fixation) or a reconstruction plate, for appropriate reduction and fixation of the injury. These 708 cases, and the duration of operating time required for the procedures, puts a considerable burden on the emergency operating theatres. Kalantzis et al7 showed that over a five-year period their maxillofacial emergency workload doubled, and that the mean delay also increased significantly. It was fractured mandibles that were most likely to be left until last. There had been no reduction in the delays in other emergency operating.
42
D. Hammond et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 39–42
The question that needs to be asked is: does a fractured mandible need to be operated on during an emergency list, or can it be placed on a dedicated elective maxillofacial trauma list? This would reduce the number of bed nights/admission, and save money, as in 201213 the approximate cost of an acute surgical bed was £682/night. A good bridle wire,14 appropriate analgesia, and antibiotics taken orally can be used to temporise a fractured mandible before definitive fixation.
Conclusions The results of this retrospective study show that there is currently no definitive answer to the question of when is the most appropriate time to provide appropriate fixation for a fractured mandible. They suggest that neither the grade of surgeon, nor whether the injury is unilateral or bilateral, affects the complication rate. We hope that they may stimulate a prospective study that deals with “time to theatre after injury”, to provide better evidence and hopefully a definitive answer.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission No ethics approval was required. All data were anonymised.
References 1. Champy M, Pape H-D, Gerlach KL, et al. The Strasbourg miniplate osteosynthesis. In: Kruger E, Schilli W, editors. Oral and maxillofacial traumatology, Vol 2. Chicago: Quintessence; 1986. p. 19–43. 2. Prein J, editor. Manual of internal fixation in the craniofacial skeleton. New York: Springer; 1998. 3. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 1985;23:77–91. 4. Czerwinski M, Parker ML, Correa JA, et al. Effect of treatment delay on mandibular fracture infection rate. Plast Reconstr Surg 2008;122:881–5. 5. Wagner WF, Neal DC, Alpert B. Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 1979;37:97–100. 6. El-Maaytah M, Upile T, Newman L. Survey of maxillofacial ‘out of hours’ operating in the United Kingdom. Br J Oral Maxillofac Surg 2009;47:320–2. 7. Kalantzis A, Weisters M, Saeed NR. Delays in emergency oral and maxillofacial operations: 5 years later. Br J Oral Maxillofacial Surg 2012;50:141–3. 8. Moulton-Barrett R, Rubenstein AJ, Salzhauer MA, et al. Complications of mandibular fractures. Ann Plast Surg 1998;41:258–63. 9. Maloney PL, Welch TB, Doku MC. Early immobilization of mandibular fractures: a retrospective study. J Oral Maxillofac Surg 1991;49:698–702. 10. Anderson T, Alpert B. Experience with rigid fixation of mandibular fractures and immediate function. J Oral Maxillofac Surg 1992;50:555–61. 11. Seemann R, Schicho K, Wutzl A, et al. Complication rates in the operative treatment of mandibular angle fractures: a 10 year retrospective. J Oral Maxillofac Surg 2010;68:647–50. 12. Katsarelis H, Lees T, McLeod N. Mandibular fractures – towards a national standard for time to theatre – national audit by the BAOMS Trauma Specialist Interest Group. Br J Oral Maxillofac Surg 2016;54:796–800. 13. Reference costs 2012 to 2013 – Gov. UK. Available from URL: www.gov.uk/government/uploads/system/uploads/attachment data/file/261154/nhs reference costs 2012-13 acc.pdf Last accessed 3 November 2017. 14. Perry M, Holmes S, editors. Atlas of operative maxillofacial trauma surgery: primary repair of facial injuries. New York: Springer; 2014.