INTRODUCTION:

Indonesia recorded an increase of 7196 (6.59%) road traffic accidents (RTA), totaling 116411 cases in 2019.¹ This increase raised concern for an increasing number of mandible fractures, as traffic accident is the leading cause of maxillo facial fracture, specifically mandible fractures, in developing countries such as Indonesia, which imposed a great burden to almost every developing countries’ economy due to lengthy hospital stay, disabilities, and socioeconomic hit amongst productive population.^2-5

Mandible fracture, the most common maxillofacial fracture, is a breach in the continuity of the mandible due to impaction exceeding the mandible’s ability to compress and stretch.⁶ It has a high prevalence around the globe, reflected by more than 13000 cases in the United States of America (USA) within four years, with a pattern that varies a lot depending on several factors such as socioeconomic, demographic, environmental, and cultural factors.^7,8 The mandible fracture can be classified based on its anatomy with the Arbeitsgemeinschaft für Osteosynthesefragen Craniomaxillofacial (AO CMF) Level-2 classification.⁹ Treatment aims to improve function and aesthetics, but the postoperative complication rate is still high, around 15% - 58.1% of the treated patients.¹⁰

Several previous Indonesian studies of mandible fractures were conducted at Sanglah Hospital Denpasar, with 45 cases in 3 years; Ulin Hospital Banjarmasin, with 60 cases in a year; Hasan Sadikin Hospital Bandung, with 346 cases in 4 years; and Adam Malik Hospital Medan, with 57 cases in 8 months.^11,12,13However, previous research on the outcome of mandible fracture in Indonesia is still scarce and was conducted only in Adam Malik Hospital Medan, West Indonesia.¹³

Therefore, it is necessary to study mandible fracture and postoperative outcomes in Dr. Soetomo General Hospital Surabaya, one of Indonesia’s largest central tertiary hospitals. This research may also give insights into the resilience of surgical interventions amidst crisis situations such as the recent COVID-19 pandemic.

METHODS:

This research was a retrospective descriptive study. The collected sample consisted of medical records of patients treated for mandible fractures at the Department of Plastic Reconstructive and Aesthetic Surgery between January 2018 to December 2020. The sample selection was based on inclusion and exclusion criteria. The inclusion criteria were inpatients and outpatients with mandible fractures at the Department of Plastic Reconstructive and Aesthetic Surgery who were treated for mandible fractures between January 2018 to December 2020. Medical records with incomplete information on patient identification, fracture site, and medical records with informed refusal to be treated for mandible fracture were excluded. Recorded data included were gender, age, mandible fracture site, and postoperative complication upon follow-up visits. Gender was categorized into male and female, while age was grouped into decades of life (0-9, 10-19, 20-29, and so on). Mandible fracture sites were based on the AO CMF Level-2 Classification, which divides the mandible into symphysis/parasymphysis, body, angle/ramus, condyle, and coronoid.⁹ Postoperative outcome includes complete recovery or complications that can be further listed as infection, malocclusion, nonunion, malunion, nerve injury, Temporomandibular Joint (TMJ) disorder, and dental problems.¹⁴ The collected data were tabulated and descriptively analyzed using Microsoft Excel version 16.77.1.

This study was permitted by the Health Research Ethics Committee, with the Institutional Review Board (IRB) number 0566/LOE/301.4.2/VIII/2021, with a waiver of informed consent.

RESULTS:

Table 1. Demography, fracture site, and outcome overview

Characteristics	n (%)
Gender	N=60
Male	45 (75)
Female	15 (25)
Age (Years)	N=60
0-9	2 (3.33)
10-19	10 (16.67)
20-29	27 (45)
30-39	10 (16.67)
40-49	8 (13.33)
50-59	3 (5)
Fracture site	N=104
Symphysis/parasymphysis	39 (37.5)
Condyle	28 (26.92)
Body	18 (17.31)
Angle/Ramus	13 (12.5)
Coronoid	6 (5.77)
Fracture site multiplicity	N= 60
Single	29 (48.33)
Multiple	31 (51.67)
Postoperative outcome	N= 60
Without complication	30 (50)
With complication	26 (43.33)
Malocclusion	18 (30)
Wound dehisence	8 (13.33)
Infection	6 (10)
TMJ disorder	6 (10)
Tooth problem	3 (5)
Malunion	1 (1.67)
No follow-up data	4 (6.67)

Based on the results, 60 patients diagnosed with mandible fractures were treated at the Department of Plastic Reconstructive and Aesthetic Surgery in Dr. Soetomo General Hospital between January 2018 to December 2020. The distribution based on gender showed a male predominance of 45 patients, which resulted in a male-to-female ratio of 3:1(Table 1). Almost half of the patients treated (45%) were between the age of 20-29 years (Table 1).

Table 2. Fracture site detailed distribution

Fracture site	Frequency, n (%)
Symphysis/parasymphysis	39 (37.5)
Condyle	28 (26.92)
Body	18 (17.31)
Angle/Ramus	13 (12.5)
Coronoid	6 (5.77)
Total	104 (100)

Symphysis/parasymphysis accounted for the most frequently fractured site, totaling 39 out of 104 fractures (37.5%) (Table 2) (Fig. 1). More than half of the patients (31; 51.67%) had multiple-site fracture, with an average of 1.7 fracture sites per patient (104/60) (Table 1, 3).

The most common single-site fracture was symphysis/parasymphysis, which accounted for 14 patients, while the most common combination for multiple-site fracture was symphysis/parasymphysis and condyle, which accounted for 8 patients (Table 3). Throughout their recovery period, majority of the patients (30; 50%) were satisfied and had no complaints until their last visit, while complication was experienced in 26 patients (43,33%) (Table 1). Malocclusion was the most prevalent among the patients (30%) (Table 1).

DISCUSSION:

Incidence and patterns related to mandible fracture are challenging to evaluate and vary extensively depending on several factors, such as socioeconomic, demographic, environmental, and cultural factors.⁸Therefore, these findings of mandible fracture and its outcome in Dr. Soetomo General Hospital contribute to describing the incidence and pattern, especially in Surabaya, East Java, as Dr. Soetomo General Hospital is one of Indonesia’s largest tertiary hospitals.

This study showed that the incidence of mandible fracture was predominantly male (75%). This finding was in accordance with several previous studies worldwide.^{7,11-31,15-19} These findings confirmed Hassanein’s statement that male predominance of mandible fracture is universal and still relevant.²⁰Possible explanations include that males are often their family’s breadwinners, which means they are more likely to drive and be involved in RTA. Moreover, males are more likely to engage in interpersonal violence, physical contact-related sports, alcohol consumption, and careless driving.^21,22 Although these risk factors that males have may differ in different sociodemographics, male universal predisposition highlights the urgency of male-specific measures and policy-making by the Indonesian government.

This study indicated that almost half (45%) of mandible fracture patients were aged 20-29 years. This result was in line with several previous studies, which found the 20s as the predominant age group.^15,22 This population in their 20s is at risk because they generally have many outdoor activities, which naturally increase their chances of involvement in high-impact events.¹¹ Moreover, this age group tends to drive carelessly and is more prone to being involved in interpersonal violence, therefore fracturing their mandible compared to the other age groups.²²

Figure 1. Fracture sites detailed distribution

This study found that over one-third of all mandible fracture sites (37.5%) were located on the symphysis/parasymphysis. Previous studies in Indonesia have shown that symphysis/parasymphysis remains the most frequent fracture site, ranging from 26.7% to 56.9%.^11-13 A study in the USA involving more than 13000 patients with mandible fractures also ranks symphysis as the most frequent at 19.2%.⁷ Although it is known that symphysis/parasymphysis is structurally the most robust among other sites, the high occurrence of symphysis/parasymphysis fracture is attributable to its prominent horseshoe geometry that is vulnerable to direct impact of trauma and weakened by the presence of large canine roots.^6,16 Therefore, the direct impact of trauma, especially to the anterior mandible, is more likely in developing countries such as Indonesia, as RTA (accident which happens on the street/traffic, which may at least cause injury up to mortality, and involving at least one moving vehicle), is the most common etiology of maxillofacial fractures, including mandible fractures.^2,17 Also, the popular use of half-face helmet or not wearing a helmet might not provide adequate protection against impact to the anterior region^3,5,18These findings may differ from studies in a more developed country, which may position the mandible angle as the most frequent site attributable to more frequent assault cases rather than RTA as the etiology.^18,22,23 However, this association between etiology and fracture site is often inconsistent, but rather more due to point and intensity of impact.^7,11,15

Multiple-site fracture slightly dominated the result at 51.57%, averaging 1.7 fracture sites per patient. The multiple-site fracture was also dominant in many studies, ranging from 56.8%-57.1%.^18,21 This predominance is attributable to coup-contrecoup injury and the mandible’s loci minoris resistentiae. The mandible, shaped like a hunting bow, is weakest on both ends (condyles) and strongest on the midline (symphysis). This geometry and the biomechanics caused a tendency for the condyle to fracture due to impaction on either symphysis (bilateral condyles) or parasymphysis (contralateral condyle).²⁴ Furthermore, loci minoris resistentiae of the mandible is known to be on the condyle (neck of condyle), body (mental foramen), and angles (which are relatively thinner, especially with impacted third molar). These properties may induce a more significant and concentrated tensile strain per unit area, thus increasing the probability of multiple-site fracture.²⁵

The most common combination of multiple-site fracture was symphysis/parasymphysis and condyle, which accounted for 8 patients (25.81%; 8/31), while single-site fracture was dominated by symphysis/ parasymphysis fracture with 14 patients (48.28%; 14/29). The combination of multiple-site fracture often varies between studies, such that this was similar to the findings of Sikkerimath but differed from Chen, who found symphysis/parasymphysis and angle to be more common. In contrast, the finding of single-site fracture was similar to the study done by Chen.^23,26 Variation of multiple-site fracture is possible, as the mandible has three different loci minoris resistentiae: condyle, angle, and body.²⁴ Variations of single-site fracture, however, are said to be associated with differences in socioeconomic and ethnicity between the studied locations, where the developing country tends to show symphysis/parasymphysis is the most frequent, while in developed countries, it is exceeded by angle fracture.²³ In this study, both multiple and single-site fractures involved symphysis/parasymphysis, suggesting a high frequency of anterior impact to the mandible. Full-face helmets were recommended to reduce the chances of multiple-site fracture by ten times because they provide adequate protection to the anterior mandible and reduce the chances of possible coup-contrecoup injury and isolated anterior fracture.¹⁸

Upon follow-up visits, postoperative outcome data showed that majority of all patients (30; 50%) were satisfied and had no complaints throughout their recovery period. However, 26 patients experienced complications (43.33%), with the remaining 4 patients (6.67%) were loss to follow-ups. This rate was in line with other studies, which have a complication rate of 15%-58.1%.¹⁰ Malocclusion experienced by almost one-third of the treated patients (30%) was the most frequent. This malocclusion rate was higher than what Manalu had found at 21%.¹³ The results differed since this study also covered those patients treated during the first year of the Coronavirus Disease 2019 (COVID-19) pandemic (2020) within the 3 years studied. Dr. Soetomo General Hospital implemented a policy during the pandemic to reduce medical personnel’s exposure to possible coronavirus. Namely, an extraoral approach should be applied instead of the standard intraoral approach to avoid exposure. This policy was in accordance with a review by Zimmerman that addressed issues regarding oral surgery during the COVID-19 pandemic, stating that if there were any extraoral technique as a relevant alternative to an intraoral one was possible, then it should be preferred to reduce airborne aerosolization.²⁷ Therefore, substandard treatment, such as the extraoral/transfacial approach, was prioritized, which is said to have higher chances of malocclusion due to poor occlusion visualization during plate application.²⁸ Other reasons are that it may occur due to inadequate or improper fracture reduction, inadequate immobilization, and one-sided use of masticatory muscle (unbalanced chewing).²⁹ Another factor was that there was insufficient data on follow-ups, long enough to evaluate the malocclusion, which would eventually subside as the wounds healed.

ACKNOWLEDGMENTS:

Authors would like to thank Dr. Soetomo General Hospital staffs who have helped and assisted in data collection. This study was funded solely by the authors and did not receive and involve any funding from other parties. This study was permitted by the Health Research Ethics Committee, with the IRB number 0566/LOE/301.4.2/VIII/2021 with a waiver of informed consent.

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Received on 18.09.2024 Revised on 04.02.2025

Accepted on 24.04.2025 Published on 05.09.2025

Available online from September 08, 2025

Research J. Pharmacy and Technology. 2025;18(9):4505-4509.

DOI: 10.52711/0974-360X.2025.00646

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Multiplicity	Fracture site combinations	Patient n (%)
Single	Symphysis/parasymphysis	14		29 (48.33)
	Condyle	7
	Body	3
	Coronoid	3
	Angle/Ramus	2
Multiple	Symphysis/parasymphysis and condyle	8	20	31 (51.67)
	Symphysis/parasymphysis and body	5
	Symphysis/parasymphysis and angle/ramus	2
	Body and angle/ramus	3
	Body and condyle	1
	Condyle and angle/ramus	1
	Symphysis/parasymphysis and condyle and body	3	9
	Symphysis/parasymphysis and condyle and angle/ramus	3
	Symphysis/parasymphysis and condyle and coronoid	2
	Body and condyle and angle/ramus	1
	Symphysis/parasymphysis and body and condyle and angle/ramus	1	2
	Symphysis/parasymphysis and body and condyle and coronoid	1
Total		60 (100)