Determinants of surgical decisions about mandible fractures.
OBJECTIVE
The study goal was to explore contextual patient- and surgeon-related characteristics that influence the perception of injury severity and treatment strategy for mandible fractures.


METHODS
After reviewing plain radiographs of 22 patients with mandible fractures, 18 oral and maxillofacial surgeons were queried on summary severity ratings and treatment decisions for each injury. Subsequently, they were asked to indicate how various hypothetical fracture and patient-specific factors would alter their perception of injury severity and original treatment recommendations. The effect of the level of clinician trauma expertise on perception of injury severity and treatment choice was also assessed.


RESULTS
Each of the fracture-specific characteristics-number of constituent fractures, fracture complexity, degree of displacement, and summary injury severity-influenced the choice of treatment modality. Surgeon-specific characteristics were related to both perception of injury severity and treatment choice. Although clinicians with greater trauma loads tended to provide higher summary severity ratings for the same range of injuries (P <.001), they appeared to recommend maxillomandibular fixation for a much broader spectrum of injury severity (R = -0.42). Surgeons' perception of injury severity appeared to escalate with increasing damage to the soft tissue envelope; the influence of patient-related risk factors was less distinct. More than half of the surgeons suggesting maxillomandibular fixation for a particular case changed their treatment recommendation to rigid internal fixation on learning that the patient was noncompliant.


CONCLUSIONS
Clinical decision making for mandible fractures is not a precise and fully reliable activity. Contextual factors (fracture, patient, and surgeon related) appear to influence the clinical decision and may be responsible for the existing variations in practice patterns.
Shetty
Vivek
V
Section of Oral and Maxillofacial Surgery, 23-009 UCLA School of Dentistry, 10833 Le Conte Ave, , Los Angeles, CA 90095-1668 , USA. vshetty@ucla.edu
Atchison
Kathryn
K
Der-Martirosian
Claudia
C
Wang
Jianming
J
Belin
Thomas R
TR
D000704:Analysis of Variance; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D002983:Clinical Competence; D015331:Cohort Studies; D003657:Decision Making; D005151:Facial Injuries / Q000145:classification; D005593:Fracture Fixation, Internal; D006801:Humans; D015601:Injury Severity Score; D019248:Jaw Fixation Techniques; D004204:Joint Dislocations / Q000145:classification / Q000601:surgery; D008337:Mandibular Fractures / Q000145:classification / Q000601:surgery*; D010347:Patient Care Planning; D019239:Practice Patterns, Dentists'; D012307:Risk Factors; D017695:Soft Tissue Injuries / Q000145:classification; D013515:Surgery, Oral; D016896:Treatment Outcome; D016312:Treatment Refusal