Original Article

Characteristics of symphysis and parasymphysis

mandibular fractures
Rabia Noreen, BDS
Muslim Khan, BDS, FCPS
1

Abstract

This descriptive study was conducted to determine the most common site of mandible fractures.
200 patients with fracture mandible who reported to Department of Oral and Maxillofacial Surgery
from April 2012 to September 2012 formed study group. Data concerning age, gender, mechanism
of injury and site of fracture evaluated and recorded on specially designed proforma. Orthopentomogram (OPG) and where necessary postero- Anterior and right and left lateral oblique views of the
mandible were used to diagnose the fracture site. Fracture mandible was predominantly common in
males (84%) as compared to females (16%) with male to female ratio of 5.25:1. The age range was
2-65 years with mean age of 21.45 S.D 12.59 years. The most common age group involved was 21-30
years (30%) and road traffic accident was the common mechanism of injury (57%) followed by fall
(31.5%). Parasymphysis was the most common site when mandible was fractures at a single site i.e.,
43%, while parasymphysis and angle fracture combination was observed in 31%. The study revealed
that majority of the patients were young adult males. The most common etiological fracture was road
traffic accident and isolated parasymphysis was the most common fracture site.
Key Words: Fracture mandible, Symphysis, Parasymphysis, Road traffic accident.
Introduction

Mandible is the strongest bone of facial skeleton but
it is fractured most frequently because of its prominent
position, anatomic configuration, mobility and less bone
support.1 It is the only mobile bone of facial skeleton and
it plays an important role in mastication, phonation,
deglutition and maintenance of dental occlusion.2

Fracture mandible accounts for 36%-59% of maxillofacial trauma. The large variability in prevalence is
due to variety of contributing factors such as gender,
age, environment and socioeconomic status of patient.3
About 44.6 to 74.4 kg/m energy is required to fracture
it which is about the same as the zygoma and about
half that for the frontal bone.4 Fracture mandible may
occur alone or in combination with other facial injuries. Fracture site depends upon mechanism of injury,
magnitude and direction of impact force, prominence of
mandible and anatomy of site. The common etiological
factors are road traffic accidents, falls, assaults, sports
injury, firearm injury, and industrial accidents. These
Resident Trainee (TMO) Oral and Maxillofacial Surgery, Khyber
College of Dentistry Peshawar Email. rabia_noreen86@yahoo.com
Cell. 03348400792
2
Associate Professor Oral and Maxillofacial Surgery, Khyber College
of Dentistry, Peshawar University Campus
Received for Publication: February 7, 2014
Accepted:
February 21, 2014
1

Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)

etiological factors depend upon geographic location,

physical activity, social, cultural and environmental
factors.5
In third world countries road traffic accident is
the common cause of mandibular fracture due to lack
of implementation of the traffic laws, while alcohol
related interpersonal violence and physical assault is
the leading cause in developed countries. Road traffic
accident is the most common causative factor in young
adults and fall in younger population. The highest
incidence is seen in the age group of 21-30 years and
lowest incidence is observed in the age group above 60
years and below 5 years. Recent data indicates a male
to female ratio of 3:16.

According to Ellis et al 33% of mandible fractures
occur at body followed by condylar process 29% and
angle 23%7. Gilven has reported that 34% fractures
occur at body, angle 25% and symphysis 20%.8
Fracture mandible if not treated or incorrectly
treated can lead to significant functional and aesthetic sequale including facial asymmetry, malocclusion,
temporomandibular joint dysfunction and osteomylitis.9
Current established methods in the management of
mandibular fractures include conservative treatment
with maxillomandibular fixation by dental wiring, arch
46

Mandibular fractures

bars and Gunning splints, open reduction and intraosseous wiring, open reduction with rigid internal fixation
by miniplates, non compression plates, compression
plates and lag screws.10

Table 1: Age distribution of mandibular

fractures
S. No

Age range
(years)

No. of patients
(n)

Percentage

The purpose of this study is to determine the most
common site of fracture mandible associated with
symphysis and parasymphysis fractures and to give
possible recommendations for the need to do further
research studies.

1.

1-10

48

24.0

2.

11-20

53

26.5

3.

21-30

60

30.0

4.

31-40

23

11.5

5.

41-50

13

6.5

MethodOLOGy

6.

51-60

1.0

7.

61-70

0.5

Total

200

100.0

This study was carried out in the Department

of Oral & Maxillofacial Surgery, Khyber College of
Dentistry, Peshawar from April 2012 to September
2012. A total of 200 patients presented with mandible
fracture were recruited in the study. Approval of hospital ethical review committee was taken. After taking
consent thorough history was taken followed by clinical examination of patients presenting with fracture
mandible. Orthopentomogram (OPG) was the standard
radiograph and when required was supplemented by
Postero-anterior (PA) view and left and right lateral
oblique view of the mandible. The data was recorded
on specifically designed proforma and evaluated and
analysed by applying descriptive statistics using SPSS
version.17
Results
A total 200 patients were recruited in the study.
Amongst them 168 (84%) were males and 32 (16%)
females. The male to female ratio was 5.25:1. (Fig 1).
The age of Patients at the time of presentation of mandibular fracture ranged from 2-65 years with mean age
of 21.4512.59 years. Majority of the patients reported
in the third and second decade of life i.e. 30% and 26.5%
respectively. Only 24% of patients were under 10 years
of age. The details are given in Table 1.

The most common cause of fracture mandible was
Road traffic accident (RTA) accounting for (57%) of

Table 2: Mechanism of injury of

mandibular fractures
S.
No.

Mechanism of
injury

No. of
patients
(n)

Percentage

1.

Fall

63

31.5

2.

Assault

11

5.5

3.

Road traffic accident

114

57.0

4.

Sports

1.0

5.

others

10

5.0

200

100.0

Total

total followed by fall (31.5%). Details of mechanism of

injury are given in Table 2. Out of symphysis and parasymphysis fracture mandible, isolated parasymphysis
is the most common site fractured (43%) followed by
parasymphysis and angle in combination (31%) and
parasymphysis and condyle (28%). The details are
shown in Table 3.
Discussion
Mandible is the strongest and heaviest bone of
facial skeleton but it is prone to fracture due to specific reasons (1). It is an open arch. (2) It is located in
the lower portion of the face. (3) It is the mechanism
of hyperextension and hyperflexion of head in traffic
accidents. (4) It gets atrophy as result of aging.11

The results of epidemiologic surveys on the causes,
incidence and distribution of mandible fracture vary
with geographic region, socio economic condition, culture characteristics and era.12

Fig 1. Gender Distribution of Mandibular Fractures

In the present study male to female ratio of 5.25:1
showed that maxillofacial trauma involving fracture
mandible is predominantly common in male population
in this part of world. This finding is consistence with

Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)

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Mandibular fractures

Table 3: Site distribution of

mandibular fractures
S.
No.

Site

No. of
patients
(n)

Percentage
(%)

Parasymphysis

43

21.5%

Symphysis

17

8.5%

Parasymphysis +
Angle

31

15.5%

Parasymphysis +
Condyle

28

14%

Parasymphysis +
Subcondyle

23

11.5%

Parasymphysis +
Body

4.5%

Parasymphysis+
Bilateral Condyle

12

6%

Parasymphysis +
Ramus

2%

Parasymphysis +
Symphysis

1.5%

10

Symphysis + Bilateral Condyle

4.5%

11

Symphysis + Angle

3%

12

Symphysis + Ramus

2%

13

Symphysis + Subcondyle

3.5%

14

Symphysis + Condyle

2%

Total

200

100

the results of previous studies conducted all over the

world.13,14,15 The relatively high male to female ratio is
due to the fact that males are engaged more in outdoor
activities while females are confined to indoor activities.
The predominant age group having fracture symphysis
and parasymphysis was 21-30 years followed by 11-20
years, these findings are similar with the results of
previous studies.16,17,18,19 However these findings are in
contrast to other studies where the dominant age group
having a high incidence of fracture were 0-10 years20
and 11-20 years.21 The possible explanation for higher
frequency of fractures in age group 21-30 years is that
people in this period of life are more active regarding
high speed transportation, sports, fights, violent activities and industry. The lower frequencies of very young
and very old age groups are due to lower activities of
these age groups.
In the present study road traffic accident is the
leading cause of fracture mandible followed by fall
from height. Previous epidemiological studies reported
Pakistan Oral & Dental Journal Vol 34, No. 1 (March 2014)

similar findings about cause of maxillofacial injuries

in developing countries.2,15,16 This may be due to lack
of seatbelt law obligation, over speeding, overloading,
under age driving and poor condition of roads and
vehicles. However in western countries assault and
interpersonal violence is the major cause of fractures
due to alcohol abuse and use of illicit drugs.9,22 Fracture
parasymphysis was the most common fracture site in
this study followed by parasymphysis and angle in
combination similar to the results of study conducted
by Dongas and Hall23 and Czerwinski et al9 and Elgehani and Orafi1 but in contrast to study by Natu et al
where fracture parasymphysis plus subcondyle was the
common combination. In another study conducted by
Subhashraj et al14 fracture parasymphysis and condyle
was the usual combination.

Mandible is similar to an architectural arch which
distributes the applied force along its length but not
being a smooth curve in a uniform cross-section. Areas of
mandible where force per unit area developed is greater
results in increased concentration of tensile strength
and fracture occurs at the site of maximum convexity
of the curvature. The reason for increased frequency
of parasymphysis fracture is probably the presence of
permanent tooth buds in children presenting a high
tooth to bone ratio while length of canine root weakens
the parasymphysis in adults resulting in its fracture.4
Angle is fractured most commonly due to presence of
unerupted third molar that makes this region weakest
point.24
The combination of parasymphysis and condyle
fracture is probably due to the horizontally directed
impact to parasymphysis leading to its fracture; this
axial force of impact against parasymphysis is transferred to cranial base through the condyle resulting in
condylar fracture due to concentration of tensile strain
at the condylar neck.4
Conclusions and Recommendations
Fracture mandible is common in young adult
males. The most common etiological factor was road
traffic accident followed by fall, while the most common
fracture site was parasymphysis when mandible was
fractured at a single site, followed by parasymphysis
and angle in combination.

As there is high frequency of mandibular fractures
in developing countries due to road traffic accidents followed by fall so to reduce such incidence of road traffic
accident, it is recommended that the laws regarding
the precautions like seat belts, motorbike wheeling and
48

Mandibular fractures

traffic rules should be improved and must be enforced

strictly. Parents should be educated about consequences
of fall in children.

12 Haung RH, Prather J, Indrsano T, An epidemiological survey

of facial fractures and concomitant injuries. J Oral Maxillofac
Surg 1990; 48: 926-32.

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