11. geriatric maxfac trauma(50) Dr. RAHUL TIWARI

PRESENTED BY
Dr RAHUL TIWARI
3rd
Yr. MDS
Dept. of Oral and Maxillofacial Surgery
MAXILLOFACIAL TRAUMA IN
GERIATRIC PATIENTS

 Introduction
 Age as a factor in facial trauma repair
 Tissue changes in the aging face
 Systemic considerations
 Common mechanisms of injury
 Type and severity of injury
 Special considerations in management
 Postoperative complications
 Journal watch
Contents
09/19/16 09:34 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 2

Introduction
“ELDERLY PATIENTS ARE LESS FREQUENTLY INJURED
BUT MORE SERIOUSLY INJURED”
09/19/16 09:34 AM RT/11/GERIATRIC MAXFAX TRAUMA/50 3

One must take into account:
The variability of changes related to aging among individuals
and the inconsistent response of organ systems in the same
individual to traumatic stress
Pre-injury disease processes
The increased likelihood of poly pharmacy

Emergency surgery has been associated with a 31%
morbidity rate and a 20% mortality rate in patients older than age 70
compared to the 6.8% morbidity rate and 1.9% mortality rate following
elective surgical procedures in the same age group
A B C
Keller SM, Markovitz LJ, Wilder JR, et al: Emergency and
elective surgery in patients over age 70. Am Surg 1987;
51(11):636.

Makinodan has described aging as "an inherent,
progressive impairment of function with passage of time,
which cannot be averted and which causes individuals
to become more vulnerable to death."
Makinodan T: Biology of aging. In Meakins JL,
McClaran JC (eds): Surgical Care of the
Elderly.Chicago, Year Book, 1988, p 63
Age as a factor in facial trauma repair

Systemic Theories
 Neuroendocrine theory: Decrease in neurons and hormone receptors
 Immunologic theory: Altered immunoregulatory genes that increase
autoimmune reactions and cause decrease in normal Immune response
Molecular Theories
 Free radical theory: Levels of antioxidants and DNA repair enzymes
decrease, leading to increased tissue damage by free radicals
 Alteration of macromolecules: Gradual cross-linking of collagen, alteration of
proteins, or accumulation of waste products leads to degenerative change of
tissue structure
Genetic Theories
 Program theory: An intrinsic self-destruct program is carried out by
senescence genes
 Stochastic theory: A gradual accumulation of genetic alterations and
rearrangements or errors in transcription occur
Theories of aging

Biologic effects of aging
General changes
Weight distribution
Body proportion alterations
By age 60, the body weight of a healthy
human has peaked and begins to decrease.
Levels of circulating proteins are decreased,
proportion of adipose tissue is increased, and
there is a loss of total body water
Anatomy and physiology of the aging process: Oral Maxillofac Surg
Clin North Am 1996;8:149.

The inflammatory and proliferative responses are decreased,
with delayed angiogenesis, delayed epithelialization, and
delayed remodeling
There is a measurable change in fibroblast function with age.
Migration, rate of synthesis, cross linking of collagen fibrils
and cell life of fibroblasts are all decreased
Gersein AD, Philips TJ. Rogers GS, et al: Wound healing and
aging. Dermatol Clin 1993;11:749
Wound healing in elderly

In addition to the diminished cellular responses,
healing is affected by concurrent medical conditions
• Cardiovascular hemodynamics
• Pulmonary reserve
• Nutritional status
• Immunosuppressive medication
• Tissue and organ perfusion
• Skin quality
• Social habits (smoking)
• Psychological and motivational behavior
• Hematologic inadequacies
• Immunologic changes
• Neuroendocrine dysfunction
• Gastrointestinal and renal impairment
• Musculoskeletal deterioration
• And integument changes

Age associated immunologic changes appear to
play a critical role in wound repair and healing
The body's ability to produce antibodies
quantitatively and qualitatively declines with age.
T-cell function and production are significantly
affected.
Gradual decrease in the number of lymphoid cells
Decrease in cell mediated and humoral responses to
specific antigenic stimuli
Miloro M, McCormick SU; Wound healing and immunity. In
Surgical Care of the Elderly. Oral Maxillofac Clin North Am
1996;8(2):159

Prophylactic use of antibiotics (when the potential for infection
is increased)
Longer maintaining of sutures in place (wound healing is
delayed)
Excision of ragged wound edges (vascularity is reduced)
Rigid fixation for bone fractures (to achieve primary bone
healing when open reduction is indicated)
Prolonged period of immobilization (when closed reduction is
indicated)
Gersein AD, Philips TJ. Rogers GS, et al: Wound healing and
aging. Dermatol Clin 1993;11:749
Wound management in the elderly

Soft tissue changes :
Begin to occur around the age of 30
Orbital region –
Progressive weakening of the orbital septum
Lateral canthus slant downward resulting in the
illusion of decreased eye size
Forehead wrinkles become more noticeable and deepen
Tissue changes in the aging face

Nasal region -
Deepening of the Nasolabial folds
Gradual drooping of the nasal tip
Perioral region -
Downward drooping of the commissures
A drooping of the lower lip occurs and is often
accompanied by an accentuation of the labiomental
fold
Vertical wrinkles emanating from the upper and lower
lips
Accentuated with the loss of teeth and thus the loss of
support for the upper and lower lips
This change is magnified as alveolar bone resorption
follows tooth loss

Aging skin-
Generalized thinning of the epidermis
Less function in the skin appendages
Thickness of the dermis decreases as a result of loss of
elastic and collagen fibers
A decrease in hyaluronic acid production, leading to a low
water binding capacity
Loss of elasticity

Conversely -
Facial scars in the older patient tend to mature faster
and have a shorter erythematous and hypertrophic
phase
Concealment of incision lines in open reduction
techniques may be easier owing to the accentuation
of the lines of facial expression, contour lines, and lines
of dependency
Larrabee WF, Sutton D, Carlisle KS: A histologic and mechanical
study of aging skin. Plastic and Reconstructive Surgery of the Head
and Neck, Mosby, 1984

Skeletal tissue changes :
Usually changes are secondary to tooth loss,
Although qualitative changes like
osteoporosis should also be considered

Tension forces result in bone deposition and pressure forces result in bone
resorption
A variety of control mechanisms may be involved, including heredity,
hormonal factors, local PH, enzymatic agents, local oxygen tension,
bioelectric potential, local induction phenomena, and others
Long-term denture wearing has been associated with increased alveolar bone
resorption
Alveolar resorption is approximately four times greater in the mandible than
in the maxilla

Bradley performed angiographic studies and he
found that in many older individuals, an inferior
alveolar artery could not be found and in others,
the vessel was greatly reduced in size
Bradley also demonstrated the presence of a
periosteal plexus of vessels along the inferior
border of the mandible made up of branches of
the buccal, lingual and facial arteries

Another anatomic factor of importance is the position of the
inferior alveolar neurovascular bundle
Bundle may lie on the superior aspect of the residual ridge
just below the mucosa. As Bruce and Strachan suggest, the
intraoral approach might therefore be more hazardous to
the bundle than the extra oral approach
Bradley JC: Age changes in the vascular supply of the mandible. Br DentJ
132:142, 1972
Bruce RA, Strachan DS: Fractures of the edentulous Study. J Oral Surg
34:973, 1976

Branzi and Quintarelli have shown that the maxillary artery
may be more prone to atheroma than any other artery in
head and neck
As maxillary alveolar bone is lost, the distance between the
maxillary sinus floor and the residual ridge decreases, and the
ratio of sinus space to bone increases.
The lateral wall of the maxillary sinus is often thin, and the
combination of these factors can produce a severely
comminuted le fort I, or "eggshell,' fracture

 Altercations and Fall
 MVA
 Pathological
 Spontaneous
Common mechanisms of injury

Zachariades and colleagues :
Majority of fractures were found in the mandible
Most of the mandibular fractures (42%) were condylar
region ,One third of them were bilateral
Body(25%), ascending ramus or angle (21%), and the
symphysis (11.5%)
Le fort II and two Le fort III fractures were more among mid
face fractures
Zygomatico-orbital # more in elderly females
Zachariades N, Papavassiliou D, Triantafvllou D. et al:
Fractures of the facial skeleton in edentulous patients. J
Maxillofac Surg 12:262, 1984
Type and severity of injury

Special considerations in management
Technique for treatement
1.Closed reduction with splint fixation
2.Open reduction (intraoral or extraoral) with transosseous,
circumferential wire ligation and transfixation Kirschner wires
3. Percutaneous intramedullary pinning
4. Intra oral open reduction with bone graft and maxillomandibular
fixation
5. External splint fixation appliance
6. Extra oral open reduction and fixation with malleable mesh
7. Extra oral open reduction and fixation with bone plating

Maxillomandibular fixation - open bite
Craniomaxillary suspension - palatal tipping
Rigid fixation techniques with miniplates - atrophy of the
alveolar ridges, coupled with pneumatization of the
maxillary sinuses, may preclude the use
Fractures of the partially or
completely edentulous maxilla

Key points
Establish preinjury ocular status
Establish preinjury facial trauma history
Establish sinus health history
Pearls
Consider secondary repair of facial injuries in the
medically compromised patient
Pitfalls
Failing to observe signs of systemic decline
Concluding inappropriately that the position of
the edentulous maxillary fracture is within the
boundaries of a prosthodontic salvage without
fracture repair.
Relying on denture or gunning's splints to reduce
edentulous midface fractures

Closed Reduction
Denture or acrylic splint wired to the superior surface
of the atrophic mandibular ridge
Gunning splint
Biphasic external pin appliance
Intramedullary pinning
Fractures of the Partially or
Completely Edentulous Mandible

THOMAS BRYAN GUNNING-
1885

Biphasic external pin appliance (Morris appliance)
At least two pins are placed on either side of the
fracture site. Note that the pins are not parallel but
diverge slightly from one another
Following reduction, first-phase stabilization is
obtained with the application of a connecting bar
and universal connectors
Second-phase stabilization proceeds with cold-cured
acrylic applied while the connector bar is in place

Intramedullary pinning
Consists of introducing a Steinmann pin
(5/64-inch or 3/32-inch) or Kirschner wire
(O.O35-inch or O.O45-inch) lengthwise
through the mandibular fragments once the
fracture has been reduced
The wire is usually introduced into the bone
via a small stab incision placed in the
cutaneous tissue over the chin region

Open reduction
Transosseous wires
Titanium mesh
trays
Compression
clamps
Bone plates
Bone grafts

Key points
Strive for anatomic reduction
Be cognizant of the qualitative and quantitative
changes of bone in the edentulous mandible
Pearls
Consider future prosthetic care, when open
reduction is selected for body fractures
Avoid external pin fixation treatment for grossly
displaced fractures
Pitfalls
Loss of posterior interarch distance
Selecting bone plates for rigid fixation of body
fractures
Using "ridge runner" lower dentures or inadequately
designed gunning's splints to repair displaced
mandibular fractures

Systemic
Nonunion
Malunion
Infection
Delayed healing
Complications

Treatment of fractures of the edentulous mandible, 1943 to
1993: A review of literature. Daniel Buchbinder. JOMS 1993,
51:1174-1180
1930s – MMF with gunning splint/dentures
1940s – External fixators like Roger Anderson pin fixator, Frac-
sure appliance, Pohl hook screw appliance, Thoma
peripheral bone clamp, Brenthenhurst clamp splint etc.
1950s – Joe Hall Morris external skeletal fixation (biphasic
system)
1960s – Robinson and Yoon L-plate
Journal watch

1970s – Lurhs dynamic compression plate, Sampson peri-
cortical clamp system, titanium mesh tray and autogenous
cancellous bone
1980s – EDCP’s and DCP’s
Recommendations:
For mandibular body region extra oral approach is best
Two plates should be placed in parallel whenever bone
height permits
Long rigid reconstruction plates help placing screws at
symphysis and ramal area away from fracture site and also
avoid periosteal stripping at fracture site
Lag screws can be used at fracture of symphysis region

Pathological fractures of the mandible - F. Gerhards, H.-D. Kuffner, W.
Wagner. Int. J. Oral maxillofac. Surg. 1998, 27.186-190.
 Fifty percent of the fractures had an inflammatory cause
 Severe atrophy of edentulous mandibles
 Benign tumours and cysts
 Primary or secondary malignancies
 Regardless of the cause, the majority of the fractures occurred in the body of
the mandible

Bucket handle fracture

Conservative management of the fractured atrophic
edentulous mandible H. Dexter Barber, DDS J Oral
Maxillofac Surg 59:789-791, 2001
Amount of displacement of the fractured segment is
obviously a determining factor as to whether conservative
management is a realistic option
Grossly displaced edentulous mandible fracture is not
amendable to conservative treatment and an open
reduction and internal fixation is required
However, with the atrophic edentulous mandible fracture, if
the fracture segments are not grossly displaced,
conservative management provides a viable option

Invasive Management of the Fractured Atrophic
Edentulous Mandible Robert D. Marciani, DMD J Oral
Maxillofac Surg 59:792-795, 2001
When open reduction is the procedure of choice, rigid
fixation devices should be used that will result in immediate
function and long-term resistance to hardware fracture
A titanium mesh crib with a simultaneous iliac crest bone
graft is one option
Intraoral open bone plating was associated with a high
frequency of complications
Horizontally placed bone plates may invite more frequent
complications
Miniplates may also be problematic

Treatment of atrophic mandibular fractures based on
the degree of atrophy — Experience with different
Plating systems: A retrospective study Gert Wittwer, DDS,
MD, Wasiu Lanre Adeyemo, DDS, Dritan Turhani, MD, and
Oliver Ploder, DDS, MD, PhD J Oral Maxillofac Surg 64:230-
234, 2006

Intraoral approach was predominantly used, except in
cases of avulsion and comminution
Complications were only observed in Class II and III
atrophy
Major complications (10%) were observed in Class II
and III atrophy attributed to a combination of
unfavorable conditions produced by the reduced cross
section and smaller contact area of fractured ends
and sclerotic and poorly vascularized bone
Dimension of hardware used was dependent on the
category of atrophy. In fractures of Class I atrophy, 1.0-
mm plates were used, whereas Classes II and III
required more rigid fixation

Major complications associated with the plating
systems
were due to wrong indication, unstable fixation
with a
single plate and aggravated bruxism
postoperatively
Treatment must be based on the type of
fracture, degree of atrophy, and experience of
the surgeon
The use of 0.5-mm mesh crib with autogenous
bone graft yielded good results in complex
fractures with avulsion or comminution09/19/16 09:34 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 45

Review of 84 cases of # of edentulous atrophic edentulous
mandible based on degree of atrophy with use of
compression plate. Hans-George Luhr et al. JOMS
1996,54:250-4
There is obvious relation between height of mandible and
incidence of complications in healing
In # with class III atrophy, periosteal stripping should be
avoided
Compression osteosynthesis has proved to be successful
method.

A comparative study of the clinical aspects of edentulous and dentulous
mandibular fractures.
N A DE S Amaratunga JOMS 1988,46 : 3-5
Frequency and treatment of condylar fractures
did not differ much
Gunning splint with gutta percha lining can be
recommended for developing countries
Longer period of immobilization is required for
edentulous patients

Maxillofacial trauma in the elderly. Giovani Gerbino et al.
JOMS 1999, 57: 777-782
Surgical intervention is less frequently indicated in elderly
The relation of age to the immobilization period required for
healing of mandibular fractures. N A DE S Amaratunga JOMS
1987, 47: 111-113
Most fractures in children needed only 2 weeks of
immobilization , 75% of young healthy adults needed 3-4 weeks
and elderly needed 5 weeks or more.

The use of immediate bone grafting in reconstruction of
clinically infected mandibular fractures: Bone grafts in the
presence of pus
Paul D. Benson, DMD, MD, Melanie K. Marshall, DDS, MD, Mark E.
Engelstad, DDS, MD, George M. Kushner, DMD, MD,and Brian
Alpert, DDS J Oral Maxillofac Surg 64:122-126, 2006
Careful patient selection is a must, immediate bone grafting
of infected mandibular fractures, when used in conjunction
with rigid internal fixation and appropriate intraoperative
debridement, is an effective treatment modality which allows
a single surgical procedure and dramatically shortens the
course of treatment

A biomechanical comparison of 2 techniques for reconstructing
atrophic edentulous mandible fractures Matthew J. Madsen and
Richard H. Haug, DDS J Oral Maxillofac Surg 64:457-465, 2006
No significant differences noted in
mechanical behavior
In the context of functional parameters, both
of the plating techniques met or exceeded
the requirements for loading

An in vitro evaluation of miniplate fixation techniques for
fractures of the atrophic edentulous mandible B. -H. Choi, J.
-Y. Huh, C. -H. Suh, K. -N. Kim:An Int. J. Oral Maxillofac. Surg.
2005; 34: 174–177.
Two miniplate fixation technique is recommended for the
provision of adequate fracture site stability when open
reduction is indicated

11. geriatric maxfac trauma(50) Dr. RAHUL TIWARI

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11. geriatric maxfac trauma(50) Dr. RAHUL TIWARI