The Journal of TRAUMA威 Injury, Infection, and Critical Care

Cost-Based Analysis of the Treatment of Mandibular

Fractures in a Tertiary Care Center
Lisa R. David, MD, Marc Bisseck, MD, Anthony Defranzo, MD, Malcolm Marks, MD,
Joseph Molnar, MD, PhD, and Louis C. Argenta, MD

Background: The objective of this
study was to assess the cost effectiveness of
alternative treatment algorithms for the
management of isolated mandibular
fractures.
Methods: This is an institutional re-
view board–approved retrospective study
consisting of a chart review of 25 patients
who underwent operative repair of an iso-
lated mandible fracture between July 1,
1999, and June 30, 2000. Patients were
stratified into two groups: patients who
were immediately admitted to the hospital
from the emergency department (ED) ver-
sus patients who were discharged from the
ED and who returned for elective sched-
uled operative repair. Patients’ total hos-
pital charges were compared on the basis
of operating room (OR) time, operative
materials, and hospital charges.
Results: Seventeen of the study pa-
tients were directly admitted from the ED,
and eight underwent elective scheduled
operative repair. Of the patients directly
admitted from the ED, the mean age was
34.9 years (range, 19 –57 years), and the
study population consisted of 16 men and
1 woman. This group had a mean OR time
of 161 minutes, a mean OR time charge of
$1,978.66, a mean OR supply charge of
$1,049.43, a mean hospital floor charge of
$5,041.02, and an average hospital stay of
2.82 days. The treatment group of patients
undergoing scheduled operative repair (n
ⴝ 8) had a mean age of 30.3 years (range,
19 – 49 years), and all were men. This sec-
ond treatment group had a mean OR time
of 167.1 minutes, a mean OR time charge
of $2,162.03, a mean OR supply charge of
$871.00, a mean hospital floor charge of
$2,759.38, and a mean hospital stay of 0.88
days. Comparison of the two study groups
demonstrated operative charges were
made on the basis of time and materials
and were shown to have no statistically
significant difference (p ⴝ 0.753 and p ⴝ
0.289, respectively). Comparison of hospi-
tal charges revealed that patients admit-
ted directly from the ED had a mean
charge $2,276.70 higher (p ⴝ 0.019) and
stayed 1.95 days longer in the hospital
than patients discharged from the emer-
gency department who returned for elec-
tive scheduled repair. There were two
complications in the study patients; both
occurred in the group admitted directly
from the emergency room.
Conclusion: The results of this study
indicate that the most cost-effective man-
agement of an isolated mandibular frac-
ture is initial evaluation in the ED with
elective interval operative repair. This
management protocol is, of course, only
applicable if the patient is clinically stable
and has no other injuries or comorbidities
necessitating in-hospital observation.
Key Words: Mandible fracture, Fa-
cial fracture, Trauma, Cost analysis
trauma management.
J Trauma. 2003;55:514 –517.

T
raumatic injuries account for more than 12% of all med-
ical spending, estimated in 1995 at $260 billion.1 Recent
Centers for Disease Control and Prevention estimates are
similar, at more than $224 billion per year.2 Maxillofacial
injuries are a common indication for operative intervention in
tertiary trauma centers. In the United States, the annual inci-
dence of maxillofacial injuries requiring hospital treatment in
patients involved in motor vehicle crashes (MVCs) has been
estimated to be 139 per 100,000 population.3 Mandibular
fractures more commonly result from an assault or alterca-
tion. The reported cause of mandible fractures can be broken
Submitted for publication March 27, 2002.
Accepted for publication May 22, 2002.
Copyright © 2003 by Lippincott Williams & Wilkins, Inc.
From the Department of Plastic and Reconstructive Surgery, Wake
Forest University School of Medicine, Winston-Salem, North Carolina.
Address for reprints: Lisa R. David, MD, Department of Plastic and
Reconstructive Surgery, Medical Center Blvd., Wake Forest University
School of Medicine, Winston-Salem, NC 27157-1075; email:
ldavid@wfubmc.edu.
DOI: 10.1097/01.TA.0000025319.71666.2D
down as follows: altercations, 80%; MVCs, 15%; and other,
5% (e.g., falls).4
Treatment options for mandibular fractures include both
rigid and nonrigid techniques. In 1886, Hasmann5 described
the use of a screw and plating system to stabilize the jaw, and
in 1887, Gilmer6 described the use of maxillomandibular
fixation and interosseous wiring to treat mandible fractures.
Associated with a very high complication rate, the plating
technique was abandoned for more than 70 years. Michelit et
al.7 and Champy et al.,8 in 1973 and 1978, respectively,
popularized the use of plate-and-screw rigid fixation when
they reported more reasonable infection rates of 3.1% to
4.7%. Both techniques are currently used, depending on the
fracture type.
Many retrospective cost-effectiveness studies have been
performed in an attempt to distinguish the most cost-effective
surgical technique for treating isolated mandibular fractures.
Brown et al.9 and Dodson and Pfeffle10 found that if com-
plications and the entire patient costs are considered, open
reduction and rigid fixation is the most cost-effective tech-
nique. In contrast, Abubaker and Lynam,11 Thaller et al.,12
and El-Degwi and Mathog4 reported that nonrigid fixation is

514 September 2003


more cost effective if all costs are considered. Certainly, it
stands to reason that the use of plates would increase the
overall cost and operative times. However, it is the fracture
type that primarily dictates which type of fixation must be
used.
In the era of cost containment and managed health care,
it is essential to provide patients with the best medical care
while keeping cost reasonable. Most patients presenting to an
emergency room with an isolated mandible fracture will re-
quire surgical repair. The type of surgical repair is often
dictated by the fracture type and thus is not under the control
of the surgeon. The objective of this study is to assess the cost
effectiveness of our current pattern of practice for the treat-
ment of mandibular fractures. Specifically, we wanted to
assess our admission policy to see whether we could decrease
overall hospital costs. As third-party payers demand cost
containment and set ever lower reimbursement limits, and as
many of the patients at tertiary centers have no insurance, it
is in everyone’s best interest to be cost conscious.
PATIENTS AND METHODS
A retrospective chart review of all patients who under-
went operative treatment of an isolated mandible fracture
between July 1, 1999, and June 30, 2000, was performed.
These patients were selected from all patients with mandible
fractures (n ⫽ 49) who were treated by the same physicians
during that time period. This time period was chosen because
all of the patient records, including all of the costs, were
computerized. This was an institutional review board–ap-
proved study, with patient consent obtained for all study
patients. Study inclusion criteria included diagnosis of an
isolated mandible fracture, clinical stability, and adequate
postoperative follow-up documentation. Exclusion criteria in-
cluded coexisting injuries, age younger than 15 years or older
than 60 years, and failure to return for postoperative follow-
up. Twenty-four of the initial 49 did not meet these criteria,
so only 25 patients could be included in this study. All study
patients were treated at Wake Forest University Baptist Med-
ical Center, a tertiary care referral and Level I trauma center.
Surgeons in the department of plastic and reconstructive
surgery treated all study patients. Data were collected on age,
sex, mechanism of injury, surgical procedure, duration of
hospital stay, hospital charges, and follow-up.
Patients were stratified into two groups for analysis:
group 1, patients who were immediately admitted to the
hospital from the emergency department after diagnosis of a
mandible fracture; and group 2, patients who were discharged
from the emergency department after evaluation of their man-
dible fracture and who returned for elective scheduled oper-
ative repair. These patients were discharged on oral antibiot-
ics and sent home with a Waterpik and soft diet restrictions.
In addition, they were given Tylenol with codeine elixir for
pain control.
Initial decision on admission versus discharge was made
on the basis of operating room availability and travel distance
Volume 55 • Number 3
Cost-Based Analysis of Mandible Fractures
Fig. 1. Demographic breakdown of the locations of the mandible
fractures in the study patients.
between the patient’s home and the tertiary care center. The
patient’s total hospital charges were analyzed on the basis of
operating room time, operative materials, and hospital
charges. Statistical analysis was performed using a two-tailed
Student’s t test (Sigma Stat, SPSS, Chicago, IL).
RESULTS
Twenty-five patients fit the inclusion criteria and had a
total of 35 fracture sites. There were 17 patients in study
group 1 (16 men and 1 woman) who were directly admitted
from the emergency department (ED) to the hospital to await
their surgery. There were eight patients in study group 2
(eight men) who were discharged from the ER and then
electively readmitted for their surgical repair. The mean age
was 34.8 years for group 1 (range, 19 –57 years), and the
mean age was 30.3 years for group 2 (range, 19 – 49 years).
The distribution of the fractures included parasymphyseal (n
⫽ 8), body (n ⫽ 2), angle (n ⫽ 9), subcondylar (n ⫽ 8),
condylar (n ⫽ 4), and ramus (n ⫽ 4), and this was equally
distributed between both study groups (Fig. 1). Mechanism of
injury included assault (n ⫽ 16), traumatic fall (n ⫽ 3), MVC
(n ⫽ 4), and sports-related injuries (n ⫽ 2) (Fig. 2). Strati-
fication of the surgical repair included the following treat-
ment options: maxillomandibular fixation with intermaxillary
fixation screws alone (n ⫽ 16), maxillomandibular fixation
with arch bars alone (n ⫽ 7), and open reduction and internal
fixation (n ⫽ 12) (Figs. 3– 4) (Table 1). Nine (39%) patients
in study group 1 and three (28%) patients in study group 2
required open reduction and internal fixation of the fractures.
The treatment modality did not vary significantly between the
two study groups. Postoperative complications included in-
fection (n ⫽ 1) and loss of maxillomandibular fixation (n ⫽
1) secondary to patient noncompliance necessitating a second
procedure, and both of these occurred in group 1. There were
no instances of malunion, malocclusion, or nerve injury
within a mean follow-up of 18 months.
515
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Fig. 2. Demographic breakdown of the cause of the mandible
fractures in the study patients.
Group 1 had a mean operating room (OR) time of 161
minutes, a mean OR time charge of $1,978.66, a mean OR
supply charge of $1,049.43, a mean hospital floor charge of
$5,041.02, and a mean hospital stay of 2.82 days. The hos-
pital stay for this group included 1.29 days from ED evalu-
ation to surgical repair and a mean of 1.53 days from surgical
repair to discharge. Group 2 had a mean OR time of 167
Fig. 3. Illustration of a mandibular fracture treated with maxillo-
mandibular fixation alone.
Fig. 4. Illustration of a mandibular fracture treated with rigid
fixation.
516
Table 1 Analysis of the Fracture Treatment Used in
the Two Study Groups
Type repair Group 1 Group 2 Total
MMF 9 7 16
MMF/AB 6 1 7
ORIF 9 3 12
Total 24 11 39
MMF, maxillomandibular fixation.
minutes, a mean OR time charge of $2,162.03, a mean OR
supply charge of $871.00, a mean hospital floor charge of
$2,759.38, and a mean hospital stay of 0.88 days. This treat-
ment group waited a mean of 4.6 days from time of diagnosis
in the ED to scheduled operative repair.
Comparison of the two study groups demonstrated oper-
ative charges were made on the basis of time and materials
and had no statistically significant cost difference between
the two treatment groups, with p ⫽ 0.576 and p ⫽ 0.566,
respectively. Comparison of the hospital charges revealed
that the patients admitted directly from the ED had a mean
charge that was $2,276.70 higher (p ⬍ 0.05) and stayed 1.95
days longer in the hospital than patients discharged from the
ED and who returned for elective surgical repair.
DISCUSSION
Trauma patients constitute an underinsured group as a
whole; some studies demonstrate that greater than 75% of
these patients have no insurance.13 Level I tertiary trauma
centers are hardest hit by this reimbursement problem. In
addition, this population is fairly litigious; this can tie up a
significant amount of the physician’s time as well. Koenig
and Lewis14 showed at a university Level I trauma center that
approximately only 57% of trauma patients paid some portion
of their bill, whereas 30% of these cases were involved in
lawsuits. Furthermore, this is a fairly noncompliant group,
with only 54% returning for postoperative follow-up. Physi-
cians treating this patient population are to be commended.
However, we must find ways to decrease medical costs while
maintaining quality of care if these trauma centers are to
remain financially viable.
Reimbursement patterns continue to decline for most
plastic surgical procedures.15 Personnel cutbacks in many
hospitals have resulted in less available OR time, making
nonscheduled emergent procedures an increasing burden, es-
pecially when the reimbursement is minimal. The study by
Finn16 of a Level I teaching hospital revealed that only 9% of
billings were actually collected. In our study population, the
collection rate of 22.8% was a little higher. Cost containment
becomes a necessity, as all of these expenses are ultimately
borne by other patients and society as a whole.
Analysis of the data from our study indicates essentially
no difference in cost on the basis of OR supply and material
charges in these two treatment modes. The most significant
cost difference is secondary to the hospital charges. The
September 2003

hospital charges included room charges, nursing and staff
charges, and supplies. Further evaluation reveals that both
study groups spent an almost identical number of days in the
hospital from the time of surgery to the time of discharge.
The increased cost for patients admitted from the emergency
room are attributable primarily to the 1.2 days of hospital-
ization from the time of emergency room evaluation to the
time of surgery. Factors in study group 1 that seem to be
associated with time to surgical repair include OR scheduling
difficulties and amount of facial edema.
Delaying the surgery up to 7 days does not adversely
affect the outcome, even in patients with open mandible
fractures. Several previous studies17,18 show no noticeable
increase in morbidity resulting from malocclusion, infection,
or nonunion. In our study, we found no significant difference
in the infection rate or complications between the two man-
agement protocols. Delayed outpatient surgery was as safe as
admission, observation, and surgical repair in our study pop-
ulation. We have found that any type of isolated mandibular
fracture including unilateral, bilateral, open, and closed frac-
tures regardless of location can be safely managed with de-
layed outpatient surgery within 7 days of the injury. Delayed
outpatient surgery has the added bonus of not tending to
disrupt the elective operative schedule. This is not an option
if there are concomitant major risk factors19 or if the patient
has additional injuries.
CONCLUSION
Isolated mandible fractures in clinically stable patients
should be managed by initial evaluation in the emergency
room and considered for discharge with scheduled return for
surgery. This route provides the most cost-effective treatment
and the shortest hospital stay. Cost containment is a necessity
in today’s medical reimbursement climate.
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