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

PRESENTED BY Dr RAHUL TIWARI

3rd Yr. MDSDept. of Oral and Maxillofacial Surgery

MAXILLOFACIAL TRAUMA IN GERIATRIC PATIENTS

IntroductionAge as a factor in facial trauma repairTissue changes in the aging faceSystemic considerations Common mechanisms of injuryType and severity of injurySpecial considerations in management Postoperative complications Journal watch

Contents

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Introduction “ELDERLY PATIENTS ARE LESS FREQUENTLY

INJURED BUT MORE SERIOUSLY INJURED”

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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;8:149.05/03/23 11:54 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 8

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 septumLateral canthus slant downward resulting in the

illusion of decreased eye sizeForehead 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 commissuresA 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 capacityLoss 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 05/03/23 11:54 AM RT/11/GERIATRIC MAXFAX TRAUMA/50 18

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 05/03/23 11:54 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 20

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 pointsEstablish preinjury ocular status Establish preinjury facial trauma history Establish sinus health history PearlsConsider secondary repair of facial injuries in the medically compromised patient PitfallsFailing to observe signs of systemic declineConcluding 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 connectorsSecond-phase stabilization proceeds with cold-cured

acrylic applied while the connector bar is in place 05/03/23 11:54 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 31

Intramedullary pinningConsists 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 platesBone grafts


Key pointsStrive for anatomic reduction Be cognizant of the qualitative and quantitative changes of bone in the edentulous mandible PearlsConsider future prosthetic care, when open reduction is selected for body fracturesAvoid external pin fixation treatment for grossly displaced fractures PitfallsLoss 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 MalunionInfection 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/dentures1940s – 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’sRecommendations:For mandibular body region extra oral approach is bestTwo plates should be placed in parallel whenever bone

height permitsLong 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 region05/03/23 11:54 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 38

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 problematic05/03/23 11:54 AMRT/11/GERIATRIC MAXFAX TRAUMA/50 42

Treatment of atrophic mandibular fractures based on the degree of atrophy — Experience with differentPlating 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 comminution


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

Health & Medicine

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