Incidence of Mandibular Fractures Associated with Head Injury in Ninavah Governorate ( 2006-2007 )

Aims: The aims of the study are to find the incidences, types, sides and sites of mandibular fracture accompanied with head injuries in Ninavah Governorate. Materials and Methods: Data of trauma cases were collected from general, local, private hospitals and health sectors in Ninavah Governorate with a head injury and mandibular fracture for one year duration from June 2006 to May 2007. Age, etiology, types, hospitals, sides and sites, distribution were arranged in tables, chi square and P value used for statistic analysis. Results: The total number of head injury cases was (5828). The total num- ber of fractures mandible with and without head injury was (282) cases means (4.84%) of total number of head injury cases, while mandibular fracture with head injury cases incidence was (76) cases (1.3%) of total number of head injury cases . Conclusions: Children were the most common age group affect- ed by head injury, while geriatric age group was the least. Male showed high percentage than female in a ratio about 2:1. Low incidence of association between head injury and fracture mandible which means that there is no need for delaying maxillofacial treatment. Falls from height and bullet injuries were the common cause of head injury and fracture mandible (dentoalveolar fractures showed high


INTRODUCTION
The human face constitutes the first contact point in several human interactions, thus injuries and/or mutilation of the facial structures may have a disastrous on the affected person (1) .As our society becomes completely mobile and getting crowded, trauma emerges as one of the leading health problems.Injuries of the face and jaws are among the most frequent injuries seen in the emergency unit (2) .The etiology of maxillofacial injuries varies from one country to another (3) .Approximately 20% of patients with maxillofacial injuries may have an associated head injury (4) .Injuries of the maxillofacial region may be disabling, for the presence of special sense (5) .
The bones of skull comprise 22 bones, brain box 8 bones, facial skeleton 14
Head Injury: It can be defined as any alteration in the mental or physical functioning related to a blow to the head.Loss of consciousness does not need to occur (10) .Injury to the head may damage the scalp, skull, or brain.The most important consequences of head trauma are traumatic brain injury (head injury may be opened or closed).The most common causes of head injury are traffic accidents, home and occupational accidents, falls, assaults.The symptoms include loss of consciousness, confusion, drowsiness, personality change, seizures, nausea, vomiting, headache, and a lucid interval (11) .For diagnosis, the Glasgow coma scale is a tool for measuring the degree of unconsciousness and determining the severity of injury (12) , as shown in Table (1).In addition to routine neurological evaluations, computerized tomography C.T. scan , magnetic resonance imaging M.R.I. or positron emission tomography PET, electroencephalogram EEG also may be used (11) .
The aims of the present study are to find the incidence of mandibular fractures accompanied with head injuries in Ninavah Governate and to identify the common types, sides and sites of mandibular fractures associated with head injuries.This will help in establishing good treatment plan.

MATERIALS AND METHODS
The study is a prospective survey for patients with a sustained head injury and mandibular fracture.The period of this study was a one year duration starting with the first June 2006 and ending in May 2007 in Ninavah Governorate.Data were collected from general hospitals in Nineveh Governorate (Al-Jumhori Teaching Hospital , Al-Salam Hospital, Al-Mosul Hospital, Ibn-Sina Hospital) .Also the data were collected from local hospitals (Al-Khansa Hospital , Ibn-Alather Hospital, Al-Shekhan Hospital, Telafer Hospital, Sinjar Hospital, Al-Humdania Hospital, Baaj Hospital) and ( 11) health sectors and private hospitals (Al-Zahrawee Hospital, Al-Rabee Hospital, Ninavah Hospital, Al-Rahma Hospital) the study enrolled all traumatized patients attending these hospitals and health sectors.The data collected included age , sex, etiology, type of fracture, geographical allocation and hospitals, monthly distribution, mandibular bone fracture type , side, site, and number of fracture sites, distribution were arranged in tables with the incidence of each.statistical analysis was done by using Chi square and P‫ـ‬values.

RESULTS
The total number of population living in Ninavah Governorate is (2922933) persons, according to Ninavah Governorate statistics and health sector statistics.The total number of trauma cases in general were (23350) cases, head injury cases (5828) cases (25%) out of total trauma cases, while mandibular fracture with head injury cases showed an incidence of (76)cases, being (0.33%) out of total trauma cases, and (1.3%) of total number of head injury cases.The total number of fractured mandibles with and head injury was (282) cases being (1.2%) out of total trauma and (4.84%) of the total number of head injury cases.Figure (1)  showed the distribution of head injury and fractured mandible according to type of head injury, where the scalp wound recording the highest incidence.

DISCUSSION
Traumatic head injuries and associated fractures of the mandible are increasingly happening specially in the last years in our country, mostly due to war injuries and abnormal situations.
There was a significant relation in the following: age , hospital incidence, type of head injury.Scalp injury represents 48.8% of total head injury, closed head injury 4.5% mostly due to bullet and shell injury as that period had a lot of violence in the Governorate.Fall from heights was the most common cause of head injury which came in agreement with Alissa A (13) .On the contrary, Adekeye showed that the parasymphysael region was commonly affected (14) .In our study left side mandibular fractures more than the right side, this may be due to the predominance right handed peoples.In addition dentoalveolar fractures, body fractures and condyle fractures in sequence and this came in agreement with Al-Rawee RY (15), but disagreed with Schug T as most fractures occur in body followed by the condyle due to different place of the study, Al-Jumhori hospital received the major number of patients because other hospitals had no causality unit , adding to that the presence of all surgical and medical branches facilitating the shifting of trauma cases.According to age children up to 10 years were the most involved because of their high mobility.Males are more boisterous than females and are workers, fighters, drivers, explaining why they are more affected than females.Major cities higher percentage of trauma cases than other areas, because of people crowding and high dynamic actions (16) .CONCLUSIONS Trauma is not uncommon in Mosul City.Children are the most common age group affected by head injury, while geriatric age group is the least affected group by trauma.Male shows high percentage of head injury and mandibular fracture than female in a ratio of about 2:1.A low incidence of association between head injury and fracture mandible means no need for delaying maxillofacial treatment.People living in the city are more prone to trauma than rural regions, as well as those who attained Al-Jumhori Hospital.Bullet injuries and falls from height are the common cause of head injury and fracture mandible.Dentoalveolar fractures showed high incidence followed by body fractures.

Figure ( 1 )
Figure (1): Distribution of head injury& fracture mandible according to type of head injury

Table ( 2
) showed the distribution of head injury and fractured mandible according to hospitals, where Al-Jumhori Hospital re-ceived the highest number of head and mandible trauma cases.