The incidence of maxillofacial trauma has been on the rise in the developed and developing countries. Mandibular fractures account for 36–54% of all maxillofacial injuries 1. The prominent anatomical location of the mandible makes it vulnerable to fractures. The most common etiologies quoted are road traffic accidents, interpersonal violence, accidental falls, sports injuries, gunshot injuries, etc. The etiology however varies in different studies 2,3,4. The most common site of fracture according to some studies was the angle of the mandible 2,3, whereas the parasymphysis 1,5 and the body 6 of the mandible were predominant in others. Mandibular fractures usually have a predictable pattern, determined by the direction and force of the impact sustained. A blow to the symphysis or parasymphysis of the mandible prompts us to look for fractures in the subcodylar regions, the contrecoup phenomenon. However, high-speed vehicular crashes and gunshot injuries may not present with predictable patterns. Here, a unique pattern of a fracture of the mandible in a sagittal plane is presented, and the possible etiology for the unique presentation has also been discussed.
A 30-year-old woman reported to our emergency services with complaints of facial pain and swelling. Her history revealed that she had an accidental fall in her house. The patient was conscious and oriented. She had a diffuse swelling in her right cheek. Intraoral palpation revealed a step deformity in her anterior border of the ramus extending lingually in to the medial ramus of the mandible. The occlusion was minimally deranged. Radiological and routine blood examinations were advised. A posteroanterior (Fig. 1) view of the mandible was advised to analyze the mediolateral displacement in addition to the orthopantomogram. The radiographs revealed a fracture in the angle of the mandible extending medially into the ramus, resembling a fracture treated using sagittal split osteotomy. The diagnosis and the treatment options were explained to the patient. She preferred to undergo a nonsurgical management. She underwent an intermaxillary fixation (Fig. 2) performed under local anesthesia. She had an uneventful healing during her first follow-up period of 1 month.
The pattern of mandibular fractures is determined by the direction and force of impact sustained. An injury to the mandible can cause a direct fracture at the site of impact and an indirect fracture at the side opposite, the contrecoup phenomenon. However, there is no predictable pattern with high-energy impacts like gunshot injuries or high-speed vehicular crashes. The mandible gets comminuted in such injuries. In interpersonal fights and falls, injuries to the mandible often reveal a predictable pattern because of the weaker impact.
In case of accidental falls, individuals usually develop involuntary movements of the body and head that protect and minimize the impact and trauma. The individuals usually stretch their arms and rotate the head as they fall down. This often results in injury to only one half of the body resulting in unilateral fractures of the mandible and zygoma. In our case, the patient had an accidental fall resulting in a unilateral fracture of the mandible, and the impact was on the same side as the fracture.
A search in the literature for unusual fracture patterns of the mandible revealed no similar cases reported. It did show two case reports on fracture patterns similar to those resembling genioplasty cuts 7,8. The other notable study pertaining to the present case was on lingual splits occurring postoperatively after sagittal split osteotomy 9. The factors contributing to lingual splits postoperatively are the buccolingual thickness of the retromolar bone, the height of the mandible from the alveolar bone to the lower border, the method of fixation, and the presence or absence of third molars. It has been shown that the method of fixation and the height of the bone from the alveolar bone to the lower border play a significant role in unwanted splits postoperatively. The possible cause for this type of unique fracture, as in the present case, could be an oblique presentation of the mandible to the point of impact while falling down and probably the decreased height of the alveolar bone to the lower border of the mandible.
Conflicts of interest
There are no conflicts of interest.
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