- Email: [email protected]
Maxillofacial Fractures in Older Patients
J Oral Maxillofac Surg 69:2204-2210, 2011
Maxillofacial Fractures in Older Patients Kazuhiko Yamamoto, DDS, PhD,* Yumiko Matsusue, DDS,† Kazuhiro Murakami, DDS, PhD,‡ Satoshi Horita, DDS,§ Tsutomu Sugiura, DDS, PhD,储 and Tadaaki Kirita, DDS, DMSc¶ Purpose: The purpose of the present study was to analyze the trends and characteristic features of
maxillofacial fractures in older patients. Patients and Methods: The data from 247 patients aged 65 years old or older, who were treated for maxillofacial fractures at the Department of Oral and Maxillofacial Surgery, Nara Medical University, from October 1981 to March 2010, were retrospectively analyzed. Results: Of the 247 patients, 127 were men and 120 were women; 50 patients had been treated in the first third of the period, 87 in the second, and 110 in the third. Injury had most frequently occurred because of falling on a level surface (n ⫽ 126), followed by a traffic accident (n ⫽ 84). Of the fractures, 140 were in the mandible, 90 in the midface, and 17 in both. In the mandible, the fracture lines were most frequently observed at the condyle, followed by the body, exclusively in edentulous patients. In the midface, the zygoma was mostly involved. The facial injury severity scale score ranged from 1 to 10 (average 1.81). Injury at other sites of the body was found in 45 patients. Observation was most frequently chosen (n ⫽ 127), primarily for those of older age, followed by open reduction and internal fixation in 46 and maxillomandibular fixation in 41 patients. The facial injury severity scale score was greatest in patients treated by open reduction and internal fixation, followed by those treated by maxillomandibular fixation. Conclusion: Maxillofacial fractures in older patients have been increasing and showed the characteristic features of etiology, patterns, and treatment modalities. © 2011 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:2204-2210, 2011 Maxillofacial fractures occur because of various traumatic forces.1-10 The diagnosis and treatment of these fractures remain a challenge for oral and maxillofacial surgeons, demanding a high level of expertise.3 Maxillofacial fractures are typically a problem in the younger population, especially in men, because they are physically and socially active and have a greater chance of being injured in traffic accidents, assaults, and sports activities.1-10 Maxillofacial fractures in
Received from Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan. *Associate Professor. †Graduate Student. ‡Clinical Instructor. §Senior Resident. 储Clinical Instructor. ¶Professor and Chair. Address correspondence and reprint requests to Dr Yamamoto: Department of Oral and Maxillofacial Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6908-0027$36.00/0 doi:10.1016/j.joms.2011.02.115
older patients are less frequent and are mostly related to age-related changes and systemic pathologic conditions, although the incidence, etiology, and pattern of these fractures differ somewhat, depending on the geographic area and socioeconomic status.11-20 In recent years, however, traumatic injuries in the elderly have been increasing because of the increased life span with advances in medicine, resulting in a greater percentage of older people in the population, with a more active lifestyle.12,13,16,20 Therefore, the number of elderly patients seeking treatment of maxillofacial fractures is expected to increase proportionally. Substantial differences exist in the response to trauma between the older and the young and middleage populations.20 Although the principles of treatment are basically the same, the conditions, such as a limited number of the residual teeth, bone atrophy, and reduced capacity for tissue repair, influence the treatment modalities for maxillofacial fractures.13,20 Furthermore, the prevalence of pre-existing disease contributes to increased morbidity in older patients with a limited physiologic reserve of the cardiovascular and pulmonary systems.21,22 Therefore, an understanding of the etiology, pattern, and consequences of maxillofacial fractures in the elderly is essential for
2204
2205
YAMAMOTO ET AL
better treatment of these patients and also to develop more effective treatment and possibly prevent injuries.20 The purpose of the present study was to analyze the trends and characteristic features of maxillofacial fractures in older patients in terms of their etiology, patterns, and treatment modalities.
Patients and Methods A total of 247 elderly patients aged 65 years and older, seeking treatment of maxillofacial fractures at the Department of Oral and Maxillofacial Surgery, Nara Medical University, during the 28.5 years from October 1981 to March 2010, were the subjects of the present study. The data from these patients were obtained from their clinical records and radiographs and were retrospectively analyzed for demographics, cause of injury, site and severity of the fracture, injury at other sites of the body, and treatment modality. The severity of maxillofacial injuries was evaluated according to the facial injury severity scale (FISS) proposed by Bagheri et al.23 Data on age distribution, cause of injury, fracture site, and treatment modality were comparatively analyzed in 3 periods of investigation (October 1981 to March 1991, April 1991 to September 2000, and October 2000 to March 2010). Data on the cause of injury and the treatment modality were also analyzed according to age group: 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, and 90 years and older. In addition, the number of fracture lines in the mandible per patient was compared according to the residual number of teeth in the mandible (group A, 0 to 4 teeth; group B, 5 to 9 teeth; and group C, 10 or more teeth). Statistical analysis was performed using the Mann-Whitney U test and the 2 test. The institutional review board approved the study in accordance with the principles of the Helsinki Declaration.
Results The patients were 127 men and 120 women. The age distribution of male and female patients is listed in Table 1. The 247 patients accounted for approximately 10.2% of all maxillofacial fractures during the same period, with 50 observed in the first period, 87 in the second, and 110 in the third (accounting for 5.7%, 9.0%, and 19.4% of all patients with maxillofacial fracture, respectively). The number of patients aged 75 years old or older was 13 (26.0%), 38 (32.2%) and 52 (47.3%) in the first, second, and third periods, respectively. Injuries occurred at a slightly greater rate on Fridays (n ⫽ 43, 17.4%) and Wednesdays (n ⫽ 42, 17.0%), when stratified by the day of the week, and in April
Table 1. AGE AND GENDER DISTRIBUTION AND PERIOD OF INVESTIGATION
Patients (n) Gender
Period
Age (yr)
Total
Males
Females
First
Second
Third
65-69 70-74 75-79 80-84 85-89 ⱖ90 Total
64 80 49 27 20 7 247
37 46 23 10 8 3 127
27 34 26 17 12 4 120
17 20 9 2 2 0 50
20 29 17 9 9 3 87
27 31 23 16 9 4 110
Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
(n ⫽ 28, 11.3%) and August (n ⫽ 27, 10.9%) when stratified by the month. Injuries occurred frequently from 9:00 am to 9 pm (n ⫽ 152 [76.4%] of 199 patients in whom the time of the accident was recorded). A total of 232 patients (93.9%) were referred from another clinic or hospital. The departments from which the patients had been referred were identified for 187 patients (emergency department for 36 patients [19.1%], surgery and dentistry for 33 each [17.6%], orthopedics in 32 [17.1%], and neurosurgery in 26 [13.9%]). A total of 154 patients (62.3%) visited our department within 3 days after the injury. The cause of the maxillofacial injury is listed in Table 2. Of the 247 patients, 126 (51.0%) were injured by falling on a level surface, 84 (34.0%) in a traffic accident, 16 in work-related accidents, and 16 by falling from 1 level to another. In the traffic accidents, 29 patients were on a motorcycle, 28 were on a bicycle, and 17 were walking. The cause of injury did not change during the 3 periods. The age distribution showed that nearly 70% of the patients aged 75 years old or older were injured by falling on a level surface and that more than 70% of injuries in traffic accidents occurred in patients younger 75 years old. The details of the fracture site are listed in Table 3. Fractures were found in the mandible in 140 patients (56.7%), in the midface in 90 (36.4%), and in both the mandible and the midface in 17 (6.9%). The fracture site did not differ among the age groups (data not shown). In the mandible, the fracture lines were single in 93 patients (59.2%), double in 45 (28.7%), triple in 12 (7.6%), quadruple in 1 (0.6%), and were localized in the alveolar bone in 6 (3.8%). Among 229 fracture lines, 148 (64.6%) were located in the condyle, 33 (14.4%) in the body, and 24 (10.5%) in the symphysis. In the midface, fractures of the zygoma were commonly found in 77 patients (79.4%), followed by panfacial fractures in 15 (15.5%). These fractures markedly increased in the third period.
2206
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS
Table 2. CAUSE OF THE INJURY ACCORDING TO INVESTIGATION PERIOD AND AGE
Patients (n) Period
Age (yr)
Cause of Injury
Total
First
Second
Third
65-69
70-74
75-79
80-84
85-89
ⱖ90
Fall on a level surface Traffic accident Work-related accident Fall from 1 level to another Assault Sports Other Total
126 84 16 16 2 1 2 247
24 15 4 6 0 0 1 50
47 28 7 4 0 0 1 87
55 41 5 6 2 1 0 110
22 29 7 5 1 0 0 64
33 32 8 5 0 1 1 80
34 8 1 4 1 0 1 49
20 7 0 0 0 0 0 27
14 6 0 0 0 0 0 20
3 2 0 2 0 0 0 7
Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
The fracture lines in the mandible were also investigated in terms of the number of residual teeth (Table 4). Of the 157 patients, 82 had 4 teeth or less in the mandible (group A), 31 had 5 to 9 teeth (group B), and 44 had 10 or more teeth (group C). Condylar fractures were most frequently observed in each group (0.85 to 1.10 fracture lines per patient) without a difference; however, body fractures were observed at a rate of 0.33 fracture line per patient in group A, significantly greater than the 0.05 fracture line per patient in group C (P ⫽ .0245). Fractures in the other
Table 3. DETAILS OF FRACTURE SITE STRATIFIED BY INVESTIGATION PERIOD
Fracture Site Fracture site Mandible Midface Mandible and midface Total Fracture line in mandible* Condyle Coronoid process Ramus Angle Body Symphysis Alveolus Total Structure involved in midface Zygoma Maxilla Panfacial Alveolus Total
Period (n)
Total (n)
First
Second
Third
140 90 17 247
32 16 2 50
56 27 4 87
52 47 11 110
148 1 9 8 33 24 6 229
31 0 2 2 11 5 2 53
57 0 3 3 12 10 2 87
60 1 4 3 10 9 2 89
77 6 15 9 107
13 1 3 1 18
24 3 2 2 31
40 2 10 6 58
*Total of 229 fracture lines found in 157 patients with mandibular fracture. Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
parts of the mandible were less frequently observed, without a difference among the 3 groups. The treatment of maxillofacial fractures is listed in Table 5. In the analysis of all patients, observation was most frequently chosen in 127 patients (51.4%), followed by open reduction and internal fixation (ORIF) in 46 (18.6%), maxillomandibular fixation (MMF) in 41 (16.6%), transcutaneous reduction in 17 (6.9%), intramaxillary fixation in 6 (2.4%), and others in 10 (4.0%), when the treatment of 17 patients with both mandibular and midface fractures was defined as the more aggressive treatment for either of these sites. The use of observation increased from 16 patients (32%) in the first period to 70 (64%) in the third. In contrast, MMF decreased from 15 patients (30%) in the first period to 9 (8%) in the third. The use of ORIF was about 20% in each period. Observation was more frequently chosen for patients in the older age groups. MMF was exclusively chosen for 40 fractures (25.5%) in the mandible and transcutaneous reduction for 17 (15.9%) in the midface. The severity of the maxillofacial injury was evaluated using the FISS (Table 6). The FISS score ranged from 1 to 10 (average 1.81 ⫾ 1.35). Most injuries were not very serious. The FISS score was 1 in 149 patients (60.3%) and 2 in 46 (18.6%). The FISS score was not significantly different in terms of the age groups (data not shown) or the cause of the injury. The relationship between FISS and treatment modality showed that the FISS score for those undergoing ORIF had the greatest value of 2.91, followed by 2.02 in MMF. The FISS score in those undergoing ORIF was significantly greater than in those undergoing MMF (P ⫽ .0394), transcutaneous reduction (P ⬍ .0001), others (P ⫽ .0487), and observation (P ⬍ .0001). The FISS score for those undergoing MMF was also significantly greater than in the transcutaneous reduction group (P ⫽ .0004) or in the observation group (P ⫽ .0006).
2207
YAMAMOTO ET AL
Table 4. NUMBER OF FRACTURE LINES STRATIFIED BY NUMBER OF RESIDUAL TEETH IN MANDIBLE
Fracture Lines per Patient (n) Fracture Site
Total (n ⫽ 157)
Group A* (n ⫽ 82)
Group B (n ⫽ 31)
Group C (n ⫽ 44)
Condyle Coronoid process Ramus Angle Body Symphysis Alveolus Total
148 (0.94 ⫾ 0.67) 1 (0.01 ⫾ 0.08) 9 (0.06 ⫾ 0.26) 8 (0.05 ⫾ 0.22) 33 (0.21 ⫾ 0.47) 24 (0.15 ⫾ 0.36) 6 (0.04 ⫾ 0.19) 229 (1.46 ⫾ 0.67)
70 (0.85 ⫾ 0.67) 0 4 (0.05 ⫾ 0.27) 6 (0.07 ⫾ 0.26) 27 (0.33 ⫾ 0.57)† 13 (0.16 ⫾ 0.37) 1 (0.01 ⫾ 0.11) 121 (1.48 ⫾ 0.71)
34 (1.10 ⫾ 0.70) 0 3 (0.10 ⫾ 0.30) 1 (0.03 ⫾ 0.18) 4 (0.13 ⫾ 0.34) 6 (0.19 ⫾ 0.40) 1 (0.03 ⫾ 0.18) 49 (1.58 ⫾ 0.72)
44 (1.00 ⫾ 0.65) 1 (0.02 ⫾ 0.15) 2 (0.05 ⫾ 0.21) 1 (0.02 ⫾ 0.15) 2 (0.05 ⫾ 0.21) 5 (0.11 ⫾ 0.32) 4 (0.09 ⫾ 0.29) 59 (1.34 ⫾ 0.53)
NOTE. Data in parentheses are mean ⫾ standard deviation. *Number of residual teeth in mandible; 0-4 in group A, 5-9 in group B, and ⱖ10 in group C. †Significantly different from number of fracture lines per patient in body in group C (P ⫽ .0245). Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
Injury to other sites of the body occurred in 45 patients (18.2%), but was not different among the age groups (data not shown); however, 27 of 84 patients (32.1%) injured in traffic accidents and 5 of 16 (31.3%) in work-related accidents had injuries to other sites of the body at a significantly greater rate than those who had fallen on a level surface (P ⬍ .0001 and P ⫽ .0023, respectively). Of the 46 patients treated by ORIF and the 127 who were observed, 12 (26.1%) and 28 (22.0%), respectively, had injuries to other sites of the body at a significantly greater rate than those treated with MMF (P ⫽ .0207, P ⫽ .0345, respectively). The injuries were most frequently found to the head (19 patients), followed by fractures of the ribs in 11, forearm in 7, and femur in 6. Severe liver damage occurred in 1 patient.
Discussion The present study retrospectively analyzed the data of maxillofacial fractures in elderly patients and showed the trends and characteristic features of max-
illofacial fractures in these patients. Maxillofacial fractures in older patients have been increasing in recent years and reached nearly 20% of all maxillofacial fractures in the third period. These results are considered to reflect the increased life span, increased elderly population, and more active lifestyle of the older population.12,13,16,20 The present study also revealed clinical features such as the etiology, patterns, and treatment modalities of maxillofacial fractures in the older population that are different from those reported in young and middle-age patients.11-20 Understanding these characteristics could help to promote clinical research to develop more effective treatment and possibly prevent injuries.20 More than one half of all maxillofacial fractures in the elderly occurred by falling on a level surface. Falling from 1 level to another, especially from a great height, was not as common. These results were consistent with those from other studies.12-14,17,20-22,24 Falling on a level surface was most often observed in patients older than 75 years of age. These findings indicate that older patients are likely to be injured by
Table 5. TREATMENT MODALITY STRATIFIED BY INVESTIGATION PERIOD, AGE, AND FRACTURE SITE
Patients (n)* Period
Fracture Site†
Age (yr)
Treatment Modality
Total
First
Second
Third
65-69
70-74
75-79
80-84
85-89
ⱖ90
Mandible
Midface
Observation Transcutaneous reduction Intramaxillary fixation Maxillomandibular fixation Open reduction and internal fixation Other Total
127 17 6 41 46 10 247
16 4 1 15 10 4 50
41 9 2 17 17 1 87
70 4 3 9 19 5 110
25 8 2 17 9 3 64
40 4 2 14 18 2 80
26 2 2 7 9 3 49
16 1 0 2 6 2 27
14 2 0 1 3 0 20
6 0 0 0 1 0 7
75 0 3 40 36 3 157
64 17 4 1 14 7 107
*Treatment of 17 patients with both mandibular and midface fractures defined as more aggressive than for either of these sites. †Treatment shown separately for 17 patients with both mandibular and midface fractures. Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
2208
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS
Table 6. SEVERITY OF INJURY ACCORDING TO AGE, CAUSE OF INJURY, AND TREATMENT MODALITY
FISS Variable Cause of injury Fall on level surface Traffic accident Work-related accident Fall from one level to another Assault Sports Other Treatment modality Observation Transcutaneous reduction Intramaxillary fixation Maxillomandibular fixation Open reduction and internal fixation Other Total
Injury at Other Sites (n)*
Patients (n)
Range
Mean ⫾ SD
126 84 16 16 2 1 2
1-6 1-10 1-4 1-3 1 1 1-10
1.68 ⫾ 1.09 1.95 ⫾ 1.56 1.63 ⫾ 0.96 1.94 ⫾ 0.93 1⫾0 1⫾0 5.55 ⫾ 6.36
9 (7.1) 27 (32.1)† 5 (31.3)‡ 2 (12.5) 0 (0) 1 (100.0) 1 (50.0)
127 17 6 41 46 10 247
1-5 1-2 1 1-4 1-10 1-6 1-10
1.47 ⫾ 0.92 1.06 ⫾ 0.24 1⫾0 2.02 ⫾ 1.01¶ 2.91 ⫾ 2.06储 1.90 ⫾ 1.60 1.81 ⫾ 1.35
28 (22.0)§ 1 (5.9) 0 (0) 3 (7.3) 12 (26.1)# 1 (10.0) 45 (18.2)
Abbreviation: FISS, facial injury severity scale. Data in parentheses are percentages. *Head, 19; arm, 4; forearm, 7; hand, 3; scapula/clavicle, 4; rib, 11; supine, 2; pelvis, 4; femur, 6; knee, 3; tibia/fibula, 2; foot, 1; and liver, 1 (includes multiple sites). †Significantly different from fall on level surface (P ⬍ .0001). ‡Significantly different from fall on level surface (P ⫽ .0023). §Significantly different from maxillomandibular fixation (P ⫽ .0345). 储Significantly different from observation (P ⬍ .0001) and transcutaneous reduction (P ⬍ .0001), maxillomandibular fixation (P ⫽ .0394), and other (P ⫽ .0487). ¶Significantly different from observation (P ⫽ .0006) and transcutaneous reduction (P ⫽ .0004). #Significantly different from maxillomandibular fixation (P ⫽ .0207). Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
falling in daily life, probably owing to the physiologic consequences of aging, such as a reduced ability to balance and avoid environmental hazards, the presence of systemic pathologic conditions, and the use of psychotropic drugs.13,25 Injuries in traffic accidents, the most common cause of maxillofacial fractures in the young population,1-7 were observed in one third of the patients, mostly in those younger than 75 years old. This finding indicates that patients younger than 75 years old are still socially active and might be involved in traffic accidents. Injuries from falling from 1 level to another and work-related accidents were observed in a few patients, primarily those younger than 75 years old. Injuries from assaults and sports activities rarely occurred. Mandibular fractures were observed in about 60% of patients and midface fractures in about 40%, although fractures of the midface increased compared with those of the mandible and were nearly equal in the third period. Most previous studies11-13,15,17,19,20 showed the dominance of midface fractures in older patients. The distribution of fractures could vary depending on the geographic area and socioeconomic status. In the mandible, fractures were most often observed in the condyle, followed by the body and
symphysis. These results indicate that the trauma force was applied in the symphyseal region, causing indirect fractures of the condyle, with or without fractures in the symphyseal region, especially by falling on a level surface.25 However, in an atrophic mandible, such a traumatic force could result in body fractures. In patients with 4 or fewer residual teeth, body fractures were observed at a significantly greater rate than in patients with 10 or more residual teeth. A similar result was found in the published data.26 In an analysis of patients with a totally edentulous mandible, the rate of body fracture was even greater (0.38/ patient, with 25 fracture lines in 65 patients). These results can mostly be ascribed to the marked reduction of the mandibular height and vascularity, which decreases the strength of the mandible, in edentulous or almost edentulous patients.16 Fractures of the mandibular angle were not common compared with those of the mandibular body. In the midface, the zygoma was frequently involved, because it is an anatomic structure susceptible to injury by external forces.25 Fractures of the alveolar bone, as well as dental injuries, were not common in either the mandible or maxilla, probably owing to the absence of teeth in the area of traumatic impact.17
2209
YAMAMOTO ET AL
Maxillofacial fractures in the elderly were not so severe, showing an average FISS score of 1.81. The FISS score was not significantly different in patients in each age group or injured by each cause, although a few severe injuries with a high FISS score were observed in patients younger than 75 years old who had been injured in traffic accidents. Injuries to other sites of the body were observed in 45 patients (18.2%). The rate was lower than in previous studies,27-30 probably because most injuries were caused by the force of a lower impact by falling on a level surface. However, the rate of injury to other sites of the body was significantly greater in patients injured in traffic accidents and work-related accidents. Therefore, patients injured in these accidents sometimes need to be primarily treated in other medical departments.30 Injuries were commonly observed to the head, upper and lower extremities, and ribs, consistent with other studies.27,29,30 Although life-threatening injuries can sometimes be complicated in patients with maxillofacial fractures,28 no deaths were recorded in the present study. This result was partly owing to the underestimation of mortality rates in studies of maxillofacial surgery because some patients with facial injuries could die at the scene or soon after arrival and never reach the maxillofacial surgeons.27 More than one half of all patients with maxillofacial fractures were followed up without active treatment. ORIF was performed in less than one fifth of the patients. The rate of observation increased in parallel with the increase in patient age. These results might have been because older patients did not want aggressive treatment because they were not so concerned about a slight facial deformity unless function was seriously impaired.13,20 Furthermore, considering the increased risk of surgery when patients are medically compromised, these patients and their families are not generally in favor of surgery.13 MMF was mostly chosen for patients younger than 75 years old with mandibular fractures. This is mostly because the application of MMF in the elderly is limited owing to periodontal disease, the presence of a prosthesis, and the absence of teeth, and also to longer immobilization times needed for consolidation of the fractures.13 Among the treatment groups, the FISS score was greatest in patients treated by ORIF, followed by those treated by MMF. The FISS score for patients treated by these modalities was significantly greater than in patients treated by other modalities. These results indicate that aggressive treatment is sometimes required for patients with a greater FISS score, even though elderly patients are likely to be treated conservatively. Injury to other sites of the body was observed at a greater rate not only in patients treated by ORIF but also in those treated by observation compared with those treated by MMF. These results
might reflect that maxillofacial fractures in patients with injury to other sites of the body are more serious and need to be treated by ORIF or, in contrast, need to be observed if not as serious, primarily to treat the injuries to other sites of the body. It is often difficult to follow up these patients because many elderly people cannot make a required visit owing to their general condition and limited transportation means, as well as reduced life expectancy; therefore, function cannot be evaluated properly, especially in patients treated conservatively. Previous studies13,31 showed that long-term results in the elderly with major trauma did not show a substantial difference; however, age inevitably causes physiologic changes to the bones and soft tissue that render healing more difficult.13,20 Therefore, these changes should be taken into account when treating these patients, although the treatment principles are basically the same as those for young and middle-age patients.13,20 In conclusion, maxillofacial fractures in the elderly have been increasing and showed characteristic features in their etiology, patterns, and treatment modalities. Understanding these characteristics could help to promote clinical research to develop more effective treatment and possibly prevent injuries.
References 1. Iida S, Kogo M, Sugiura T, Mima T, Matsuya T: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30:286, 2001 2. Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 2003 3. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:166, 2004 4. Erol B, Tanrikulu R, Görgün B: Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 32:308, 2004 5. Ferreira PC, Amarante JM, Silva PN, et al: Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 115:1500, 2005 6. Brasileiro BF, Passeri LA: Epidemiological analysis of maxillofacial fractures in Brasil: A 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:28, 2006 7. Cheema SA, Amin F: Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan. Br J Oral Maxillofac Surg 44:232, 2006 8. Bakardjiev A, Pechalova P: Maxillofacial fractures in Southern Bulgaria—A retrospective study of 1706 cases. J Craniomaxillofac Surg 35:147, 2007 9. Erdmann D, Follmar KE, DeBruijn M, et al: A retrospective analysis of facial fracture etiologies. Ann Plast Surg 60:398, 2008 10. Lee JH, Cho BK, Park WJ: A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg 38:192, 2010 11. Falcone PA, Haedicke GJ, Brooks G, Sullivan PK: Maxillofacial fractures in the elderly: A comparative study. Plast Reconstr Surg 86:443, 1990 12. Goldschmidt MJ, Castiglione CL, Assael LA, Litt MD: Craniomaxillofacial trauma in the elderly. J Oral Maxillofac Surg 53: 1145, 1995
2210 13. Gerbino G, Roccia F, De Gioanni PP, Berrone S: Maxillofacial trauma in the elderly. J Oral Maxillofac Surg 57:777, 1999 14. Rehman K, Edmondson H: The cause and consequences of maxillofacial injuries in elderly people. Gerodontology 19:60, 2002 15. Fasola AO, Obiechina AE, Arotiba JT: Incidence and pattern of maxillofacial fractures in the elderly. Int J Oral Maxillofac Surg 32:206, 2003 16. Sidal T, Curtis DA: Fractures of the mandible in the aging population. Spec Care Dentist 26:145, 2006 17. Kloss FR, Tuli T, Hächl O, et al: The impact of aging on craniomaxillofacial trauma—A comparative investigation. Int J Oral Maxillofac Surg 36:1158, 2007 18. Subhashraj K, Ravindran C: Maxillofacial intervention in trauma patients aged 60 years and older. Indian J Dent Res 19:109, 2008 19. Royan SJ, Hamid AL, Kovilpillai FJ, Junid NZ, Mustafa WM: A prospective study on elderly patients with facial fractures in a developing country. Gerodontology 25:124, 2008 20. Chrcanovic BR, Souza LN, Freire-Maua B, et al: Facial fractures in the elderly: A retrospective study in a hospital in Belo Horizonte, Brazil. J Trauma 69:E73, 2010 21. Santora TA, Schinco MA, Trooskin SZ: Management of trauma in the elderly patient. Surg Clin North Am 74:163, 1994 22. Wade CV, Hoffmsn GR, Brennan PA: Falls in elderly people that result in facial injuries. Br J Oral Maxillofac Surg 42:138, 2004
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS 23. Bagheri SC, Dierks EJ, Kademani D, et al: Application of a facial injury severity sale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64:408, 2006 24. Werning JW, Downey NM, Brinker RA, et al: The impact of osteoporosis on patients with maxillofacial trauma. Arch Otolaryngol Head Neck Surg 130:353, 2004 25. Yamamoto K, Kuraki M, Kurihara M, et al: Maxillofacial fractures resulting from falls. J Oral Maxillofac Surg 58:1602, 2010 26. Amaratunga NA, de S: A comparative study of the clinical aspects of edentulous and dentulous mandibular fractures. J Oral Maxillofac Surg 46:3, 1988 27. Down KE, Boot DA, Gorman DF: Maxillofacial and associated injuries in severely traumatized patients: Implications of a regional survey. Int J Oral Maxillofac Surg 24:409, 1995 28. Tung T-C, Tseng W-S, Chen C-T, Lai JP, Chen YR: Acute lifethreatening injuries in facial fracture patients: A review of 1025 patients. J Trauma 49:420, 2000 29. Alvi A, Doherty T, Lewen G: Facial fractures and concomitant injuries in trauma patients. Laryngoscope 113:102, 2003 30. Thorén H, Snäll J, Salo J, et al: Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 68:805, 2010 31. van der Sluis CK, Klasen HJ, Eisma WH, ten Duis HJ: Major trauma in young and old. What is the difference? J Trauma 40:78, 1996
Maxillofacial Fractures in Older Patients Kazuhiko Yamamoto, DDS, PhD,* Yumiko Matsusue, DDS,† Kazuhiro Murakami, DDS, PhD,‡ Satoshi Horita, DDS,§ Tsutomu Sugiura, DDS, PhD,储 and Tadaaki Kirita, DDS, DMSc¶ Purpose: The purpose of the present study was to analyze the trends and characteristic features of
maxillofacial fractures in older patients. Patients and Methods: The data from 247 patients aged 65 years old or older, who were treated for maxillofacial fractures at the Department of Oral and Maxillofacial Surgery, Nara Medical University, from October 1981 to March 2010, were retrospectively analyzed. Results: Of the 247 patients, 127 were men and 120 were women; 50 patients had been treated in the first third of the period, 87 in the second, and 110 in the third. Injury had most frequently occurred because of falling on a level surface (n ⫽ 126), followed by a traffic accident (n ⫽ 84). Of the fractures, 140 were in the mandible, 90 in the midface, and 17 in both. In the mandible, the fracture lines were most frequently observed at the condyle, followed by the body, exclusively in edentulous patients. In the midface, the zygoma was mostly involved. The facial injury severity scale score ranged from 1 to 10 (average 1.81). Injury at other sites of the body was found in 45 patients. Observation was most frequently chosen (n ⫽ 127), primarily for those of older age, followed by open reduction and internal fixation in 46 and maxillomandibular fixation in 41 patients. The facial injury severity scale score was greatest in patients treated by open reduction and internal fixation, followed by those treated by maxillomandibular fixation. Conclusion: Maxillofacial fractures in older patients have been increasing and showed the characteristic features of etiology, patterns, and treatment modalities. © 2011 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 69:2204-2210, 2011 Maxillofacial fractures occur because of various traumatic forces.1-10 The diagnosis and treatment of these fractures remain a challenge for oral and maxillofacial surgeons, demanding a high level of expertise.3 Maxillofacial fractures are typically a problem in the younger population, especially in men, because they are physically and socially active and have a greater chance of being injured in traffic accidents, assaults, and sports activities.1-10 Maxillofacial fractures in
Received from Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan. *Associate Professor. †Graduate Student. ‡Clinical Instructor. §Senior Resident. 储Clinical Instructor. ¶Professor and Chair. Address correspondence and reprint requests to Dr Yamamoto: Department of Oral and Maxillofacial Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6908-0027$36.00/0 doi:10.1016/j.joms.2011.02.115
older patients are less frequent and are mostly related to age-related changes and systemic pathologic conditions, although the incidence, etiology, and pattern of these fractures differ somewhat, depending on the geographic area and socioeconomic status.11-20 In recent years, however, traumatic injuries in the elderly have been increasing because of the increased life span with advances in medicine, resulting in a greater percentage of older people in the population, with a more active lifestyle.12,13,16,20 Therefore, the number of elderly patients seeking treatment of maxillofacial fractures is expected to increase proportionally. Substantial differences exist in the response to trauma between the older and the young and middleage populations.20 Although the principles of treatment are basically the same, the conditions, such as a limited number of the residual teeth, bone atrophy, and reduced capacity for tissue repair, influence the treatment modalities for maxillofacial fractures.13,20 Furthermore, the prevalence of pre-existing disease contributes to increased morbidity in older patients with a limited physiologic reserve of the cardiovascular and pulmonary systems.21,22 Therefore, an understanding of the etiology, pattern, and consequences of maxillofacial fractures in the elderly is essential for
2204
2205
YAMAMOTO ET AL
better treatment of these patients and also to develop more effective treatment and possibly prevent injuries.20 The purpose of the present study was to analyze the trends and characteristic features of maxillofacial fractures in older patients in terms of their etiology, patterns, and treatment modalities.
Patients and Methods A total of 247 elderly patients aged 65 years and older, seeking treatment of maxillofacial fractures at the Department of Oral and Maxillofacial Surgery, Nara Medical University, during the 28.5 years from October 1981 to March 2010, were the subjects of the present study. The data from these patients were obtained from their clinical records and radiographs and were retrospectively analyzed for demographics, cause of injury, site and severity of the fracture, injury at other sites of the body, and treatment modality. The severity of maxillofacial injuries was evaluated according to the facial injury severity scale (FISS) proposed by Bagheri et al.23 Data on age distribution, cause of injury, fracture site, and treatment modality were comparatively analyzed in 3 periods of investigation (October 1981 to March 1991, April 1991 to September 2000, and October 2000 to March 2010). Data on the cause of injury and the treatment modality were also analyzed according to age group: 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, and 90 years and older. In addition, the number of fracture lines in the mandible per patient was compared according to the residual number of teeth in the mandible (group A, 0 to 4 teeth; group B, 5 to 9 teeth; and group C, 10 or more teeth). Statistical analysis was performed using the Mann-Whitney U test and the 2 test. The institutional review board approved the study in accordance with the principles of the Helsinki Declaration.
Results The patients were 127 men and 120 women. The age distribution of male and female patients is listed in Table 1. The 247 patients accounted for approximately 10.2% of all maxillofacial fractures during the same period, with 50 observed in the first period, 87 in the second, and 110 in the third (accounting for 5.7%, 9.0%, and 19.4% of all patients with maxillofacial fracture, respectively). The number of patients aged 75 years old or older was 13 (26.0%), 38 (32.2%) and 52 (47.3%) in the first, second, and third periods, respectively. Injuries occurred at a slightly greater rate on Fridays (n ⫽ 43, 17.4%) and Wednesdays (n ⫽ 42, 17.0%), when stratified by the day of the week, and in April
Table 1. AGE AND GENDER DISTRIBUTION AND PERIOD OF INVESTIGATION
Patients (n) Gender
Period
Age (yr)
Total
Males
Females
First
Second
Third
65-69 70-74 75-79 80-84 85-89 ⱖ90 Total
64 80 49 27 20 7 247
37 46 23 10 8 3 127
27 34 26 17 12 4 120
17 20 9 2 2 0 50
20 29 17 9 9 3 87
27 31 23 16 9 4 110
Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
(n ⫽ 28, 11.3%) and August (n ⫽ 27, 10.9%) when stratified by the month. Injuries occurred frequently from 9:00 am to 9 pm (n ⫽ 152 [76.4%] of 199 patients in whom the time of the accident was recorded). A total of 232 patients (93.9%) were referred from another clinic or hospital. The departments from which the patients had been referred were identified for 187 patients (emergency department for 36 patients [19.1%], surgery and dentistry for 33 each [17.6%], orthopedics in 32 [17.1%], and neurosurgery in 26 [13.9%]). A total of 154 patients (62.3%) visited our department within 3 days after the injury. The cause of the maxillofacial injury is listed in Table 2. Of the 247 patients, 126 (51.0%) were injured by falling on a level surface, 84 (34.0%) in a traffic accident, 16 in work-related accidents, and 16 by falling from 1 level to another. In the traffic accidents, 29 patients were on a motorcycle, 28 were on a bicycle, and 17 were walking. The cause of injury did not change during the 3 periods. The age distribution showed that nearly 70% of the patients aged 75 years old or older were injured by falling on a level surface and that more than 70% of injuries in traffic accidents occurred in patients younger 75 years old. The details of the fracture site are listed in Table 3. Fractures were found in the mandible in 140 patients (56.7%), in the midface in 90 (36.4%), and in both the mandible and the midface in 17 (6.9%). The fracture site did not differ among the age groups (data not shown). In the mandible, the fracture lines were single in 93 patients (59.2%), double in 45 (28.7%), triple in 12 (7.6%), quadruple in 1 (0.6%), and were localized in the alveolar bone in 6 (3.8%). Among 229 fracture lines, 148 (64.6%) were located in the condyle, 33 (14.4%) in the body, and 24 (10.5%) in the symphysis. In the midface, fractures of the zygoma were commonly found in 77 patients (79.4%), followed by panfacial fractures in 15 (15.5%). These fractures markedly increased in the third period.
2206
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS
Table 2. CAUSE OF THE INJURY ACCORDING TO INVESTIGATION PERIOD AND AGE
Patients (n) Period
Age (yr)
Cause of Injury
Total
First
Second
Third
65-69
70-74
75-79
80-84
85-89
ⱖ90
Fall on a level surface Traffic accident Work-related accident Fall from 1 level to another Assault Sports Other Total
126 84 16 16 2 1 2 247
24 15 4 6 0 0 1 50
47 28 7 4 0 0 1 87
55 41 5 6 2 1 0 110
22 29 7 5 1 0 0 64
33 32 8 5 0 1 1 80
34 8 1 4 1 0 1 49
20 7 0 0 0 0 0 27
14 6 0 0 0 0 0 20
3 2 0 2 0 0 0 7
Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
The fracture lines in the mandible were also investigated in terms of the number of residual teeth (Table 4). Of the 157 patients, 82 had 4 teeth or less in the mandible (group A), 31 had 5 to 9 teeth (group B), and 44 had 10 or more teeth (group C). Condylar fractures were most frequently observed in each group (0.85 to 1.10 fracture lines per patient) without a difference; however, body fractures were observed at a rate of 0.33 fracture line per patient in group A, significantly greater than the 0.05 fracture line per patient in group C (P ⫽ .0245). Fractures in the other
Table 3. DETAILS OF FRACTURE SITE STRATIFIED BY INVESTIGATION PERIOD
Fracture Site Fracture site Mandible Midface Mandible and midface Total Fracture line in mandible* Condyle Coronoid process Ramus Angle Body Symphysis Alveolus Total Structure involved in midface Zygoma Maxilla Panfacial Alveolus Total
Period (n)
Total (n)
First
Second
Third
140 90 17 247
32 16 2 50
56 27 4 87
52 47 11 110
148 1 9 8 33 24 6 229
31 0 2 2 11 5 2 53
57 0 3 3 12 10 2 87
60 1 4 3 10 9 2 89
77 6 15 9 107
13 1 3 1 18
24 3 2 2 31
40 2 10 6 58
*Total of 229 fracture lines found in 157 patients with mandibular fracture. Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
parts of the mandible were less frequently observed, without a difference among the 3 groups. The treatment of maxillofacial fractures is listed in Table 5. In the analysis of all patients, observation was most frequently chosen in 127 patients (51.4%), followed by open reduction and internal fixation (ORIF) in 46 (18.6%), maxillomandibular fixation (MMF) in 41 (16.6%), transcutaneous reduction in 17 (6.9%), intramaxillary fixation in 6 (2.4%), and others in 10 (4.0%), when the treatment of 17 patients with both mandibular and midface fractures was defined as the more aggressive treatment for either of these sites. The use of observation increased from 16 patients (32%) in the first period to 70 (64%) in the third. In contrast, MMF decreased from 15 patients (30%) in the first period to 9 (8%) in the third. The use of ORIF was about 20% in each period. Observation was more frequently chosen for patients in the older age groups. MMF was exclusively chosen for 40 fractures (25.5%) in the mandible and transcutaneous reduction for 17 (15.9%) in the midface. The severity of the maxillofacial injury was evaluated using the FISS (Table 6). The FISS score ranged from 1 to 10 (average 1.81 ⫾ 1.35). Most injuries were not very serious. The FISS score was 1 in 149 patients (60.3%) and 2 in 46 (18.6%). The FISS score was not significantly different in terms of the age groups (data not shown) or the cause of the injury. The relationship between FISS and treatment modality showed that the FISS score for those undergoing ORIF had the greatest value of 2.91, followed by 2.02 in MMF. The FISS score in those undergoing ORIF was significantly greater than in those undergoing MMF (P ⫽ .0394), transcutaneous reduction (P ⬍ .0001), others (P ⫽ .0487), and observation (P ⬍ .0001). The FISS score for those undergoing MMF was also significantly greater than in the transcutaneous reduction group (P ⫽ .0004) or in the observation group (P ⫽ .0006).
2207
YAMAMOTO ET AL
Table 4. NUMBER OF FRACTURE LINES STRATIFIED BY NUMBER OF RESIDUAL TEETH IN MANDIBLE
Fracture Lines per Patient (n) Fracture Site
Total (n ⫽ 157)
Group A* (n ⫽ 82)
Group B (n ⫽ 31)
Group C (n ⫽ 44)
Condyle Coronoid process Ramus Angle Body Symphysis Alveolus Total
148 (0.94 ⫾ 0.67) 1 (0.01 ⫾ 0.08) 9 (0.06 ⫾ 0.26) 8 (0.05 ⫾ 0.22) 33 (0.21 ⫾ 0.47) 24 (0.15 ⫾ 0.36) 6 (0.04 ⫾ 0.19) 229 (1.46 ⫾ 0.67)
70 (0.85 ⫾ 0.67) 0 4 (0.05 ⫾ 0.27) 6 (0.07 ⫾ 0.26) 27 (0.33 ⫾ 0.57)† 13 (0.16 ⫾ 0.37) 1 (0.01 ⫾ 0.11) 121 (1.48 ⫾ 0.71)
34 (1.10 ⫾ 0.70) 0 3 (0.10 ⫾ 0.30) 1 (0.03 ⫾ 0.18) 4 (0.13 ⫾ 0.34) 6 (0.19 ⫾ 0.40) 1 (0.03 ⫾ 0.18) 49 (1.58 ⫾ 0.72)
44 (1.00 ⫾ 0.65) 1 (0.02 ⫾ 0.15) 2 (0.05 ⫾ 0.21) 1 (0.02 ⫾ 0.15) 2 (0.05 ⫾ 0.21) 5 (0.11 ⫾ 0.32) 4 (0.09 ⫾ 0.29) 59 (1.34 ⫾ 0.53)
NOTE. Data in parentheses are mean ⫾ standard deviation. *Number of residual teeth in mandible; 0-4 in group A, 5-9 in group B, and ⱖ10 in group C. †Significantly different from number of fracture lines per patient in body in group C (P ⫽ .0245). Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
Injury to other sites of the body occurred in 45 patients (18.2%), but was not different among the age groups (data not shown); however, 27 of 84 patients (32.1%) injured in traffic accidents and 5 of 16 (31.3%) in work-related accidents had injuries to other sites of the body at a significantly greater rate than those who had fallen on a level surface (P ⬍ .0001 and P ⫽ .0023, respectively). Of the 46 patients treated by ORIF and the 127 who were observed, 12 (26.1%) and 28 (22.0%), respectively, had injuries to other sites of the body at a significantly greater rate than those treated with MMF (P ⫽ .0207, P ⫽ .0345, respectively). The injuries were most frequently found to the head (19 patients), followed by fractures of the ribs in 11, forearm in 7, and femur in 6. Severe liver damage occurred in 1 patient.
Discussion The present study retrospectively analyzed the data of maxillofacial fractures in elderly patients and showed the trends and characteristic features of max-
illofacial fractures in these patients. Maxillofacial fractures in older patients have been increasing in recent years and reached nearly 20% of all maxillofacial fractures in the third period. These results are considered to reflect the increased life span, increased elderly population, and more active lifestyle of the older population.12,13,16,20 The present study also revealed clinical features such as the etiology, patterns, and treatment modalities of maxillofacial fractures in the older population that are different from those reported in young and middle-age patients.11-20 Understanding these characteristics could help to promote clinical research to develop more effective treatment and possibly prevent injuries.20 More than one half of all maxillofacial fractures in the elderly occurred by falling on a level surface. Falling from 1 level to another, especially from a great height, was not as common. These results were consistent with those from other studies.12-14,17,20-22,24 Falling on a level surface was most often observed in patients older than 75 years of age. These findings indicate that older patients are likely to be injured by
Table 5. TREATMENT MODALITY STRATIFIED BY INVESTIGATION PERIOD, AGE, AND FRACTURE SITE
Patients (n)* Period
Fracture Site†
Age (yr)
Treatment Modality
Total
First
Second
Third
65-69
70-74
75-79
80-84
85-89
ⱖ90
Mandible
Midface
Observation Transcutaneous reduction Intramaxillary fixation Maxillomandibular fixation Open reduction and internal fixation Other Total
127 17 6 41 46 10 247
16 4 1 15 10 4 50
41 9 2 17 17 1 87
70 4 3 9 19 5 110
25 8 2 17 9 3 64
40 4 2 14 18 2 80
26 2 2 7 9 3 49
16 1 0 2 6 2 27
14 2 0 1 3 0 20
6 0 0 0 1 0 7
75 0 3 40 36 3 157
64 17 4 1 14 7 107
*Treatment of 17 patients with both mandibular and midface fractures defined as more aggressive than for either of these sites. †Treatment shown separately for 17 patients with both mandibular and midface fractures. Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
2208
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS
Table 6. SEVERITY OF INJURY ACCORDING TO AGE, CAUSE OF INJURY, AND TREATMENT MODALITY
FISS Variable Cause of injury Fall on level surface Traffic accident Work-related accident Fall from one level to another Assault Sports Other Treatment modality Observation Transcutaneous reduction Intramaxillary fixation Maxillomandibular fixation Open reduction and internal fixation Other Total
Injury at Other Sites (n)*
Patients (n)
Range
Mean ⫾ SD
126 84 16 16 2 1 2
1-6 1-10 1-4 1-3 1 1 1-10
1.68 ⫾ 1.09 1.95 ⫾ 1.56 1.63 ⫾ 0.96 1.94 ⫾ 0.93 1⫾0 1⫾0 5.55 ⫾ 6.36
9 (7.1) 27 (32.1)† 5 (31.3)‡ 2 (12.5) 0 (0) 1 (100.0) 1 (50.0)
127 17 6 41 46 10 247
1-5 1-2 1 1-4 1-10 1-6 1-10
1.47 ⫾ 0.92 1.06 ⫾ 0.24 1⫾0 2.02 ⫾ 1.01¶ 2.91 ⫾ 2.06储 1.90 ⫾ 1.60 1.81 ⫾ 1.35
28 (22.0)§ 1 (5.9) 0 (0) 3 (7.3) 12 (26.1)# 1 (10.0) 45 (18.2)
Abbreviation: FISS, facial injury severity scale. Data in parentheses are percentages. *Head, 19; arm, 4; forearm, 7; hand, 3; scapula/clavicle, 4; rib, 11; supine, 2; pelvis, 4; femur, 6; knee, 3; tibia/fibula, 2; foot, 1; and liver, 1 (includes multiple sites). †Significantly different from fall on level surface (P ⬍ .0001). ‡Significantly different from fall on level surface (P ⫽ .0023). §Significantly different from maxillomandibular fixation (P ⫽ .0345). 储Significantly different from observation (P ⬍ .0001) and transcutaneous reduction (P ⬍ .0001), maxillomandibular fixation (P ⫽ .0394), and other (P ⫽ .0487). ¶Significantly different from observation (P ⫽ .0006) and transcutaneous reduction (P ⫽ .0004). #Significantly different from maxillomandibular fixation (P ⫽ .0207). Yamamoto et al. Maxillofacial Fractures in Older Patients. J Oral Maxillofac Surg 2011.
falling in daily life, probably owing to the physiologic consequences of aging, such as a reduced ability to balance and avoid environmental hazards, the presence of systemic pathologic conditions, and the use of psychotropic drugs.13,25 Injuries in traffic accidents, the most common cause of maxillofacial fractures in the young population,1-7 were observed in one third of the patients, mostly in those younger than 75 years old. This finding indicates that patients younger than 75 years old are still socially active and might be involved in traffic accidents. Injuries from falling from 1 level to another and work-related accidents were observed in a few patients, primarily those younger than 75 years old. Injuries from assaults and sports activities rarely occurred. Mandibular fractures were observed in about 60% of patients and midface fractures in about 40%, although fractures of the midface increased compared with those of the mandible and were nearly equal in the third period. Most previous studies11-13,15,17,19,20 showed the dominance of midface fractures in older patients. The distribution of fractures could vary depending on the geographic area and socioeconomic status. In the mandible, fractures were most often observed in the condyle, followed by the body and
symphysis. These results indicate that the trauma force was applied in the symphyseal region, causing indirect fractures of the condyle, with or without fractures in the symphyseal region, especially by falling on a level surface.25 However, in an atrophic mandible, such a traumatic force could result in body fractures. In patients with 4 or fewer residual teeth, body fractures were observed at a significantly greater rate than in patients with 10 or more residual teeth. A similar result was found in the published data.26 In an analysis of patients with a totally edentulous mandible, the rate of body fracture was even greater (0.38/ patient, with 25 fracture lines in 65 patients). These results can mostly be ascribed to the marked reduction of the mandibular height and vascularity, which decreases the strength of the mandible, in edentulous or almost edentulous patients.16 Fractures of the mandibular angle were not common compared with those of the mandibular body. In the midface, the zygoma was frequently involved, because it is an anatomic structure susceptible to injury by external forces.25 Fractures of the alveolar bone, as well as dental injuries, were not common in either the mandible or maxilla, probably owing to the absence of teeth in the area of traumatic impact.17
2209
YAMAMOTO ET AL
Maxillofacial fractures in the elderly were not so severe, showing an average FISS score of 1.81. The FISS score was not significantly different in patients in each age group or injured by each cause, although a few severe injuries with a high FISS score were observed in patients younger than 75 years old who had been injured in traffic accidents. Injuries to other sites of the body were observed in 45 patients (18.2%). The rate was lower than in previous studies,27-30 probably because most injuries were caused by the force of a lower impact by falling on a level surface. However, the rate of injury to other sites of the body was significantly greater in patients injured in traffic accidents and work-related accidents. Therefore, patients injured in these accidents sometimes need to be primarily treated in other medical departments.30 Injuries were commonly observed to the head, upper and lower extremities, and ribs, consistent with other studies.27,29,30 Although life-threatening injuries can sometimes be complicated in patients with maxillofacial fractures,28 no deaths were recorded in the present study. This result was partly owing to the underestimation of mortality rates in studies of maxillofacial surgery because some patients with facial injuries could die at the scene or soon after arrival and never reach the maxillofacial surgeons.27 More than one half of all patients with maxillofacial fractures were followed up without active treatment. ORIF was performed in less than one fifth of the patients. The rate of observation increased in parallel with the increase in patient age. These results might have been because older patients did not want aggressive treatment because they were not so concerned about a slight facial deformity unless function was seriously impaired.13,20 Furthermore, considering the increased risk of surgery when patients are medically compromised, these patients and their families are not generally in favor of surgery.13 MMF was mostly chosen for patients younger than 75 years old with mandibular fractures. This is mostly because the application of MMF in the elderly is limited owing to periodontal disease, the presence of a prosthesis, and the absence of teeth, and also to longer immobilization times needed for consolidation of the fractures.13 Among the treatment groups, the FISS score was greatest in patients treated by ORIF, followed by those treated by MMF. The FISS score for patients treated by these modalities was significantly greater than in patients treated by other modalities. These results indicate that aggressive treatment is sometimes required for patients with a greater FISS score, even though elderly patients are likely to be treated conservatively. Injury to other sites of the body was observed at a greater rate not only in patients treated by ORIF but also in those treated by observation compared with those treated by MMF. These results
might reflect that maxillofacial fractures in patients with injury to other sites of the body are more serious and need to be treated by ORIF or, in contrast, need to be observed if not as serious, primarily to treat the injuries to other sites of the body. It is often difficult to follow up these patients because many elderly people cannot make a required visit owing to their general condition and limited transportation means, as well as reduced life expectancy; therefore, function cannot be evaluated properly, especially in patients treated conservatively. Previous studies13,31 showed that long-term results in the elderly with major trauma did not show a substantial difference; however, age inevitably causes physiologic changes to the bones and soft tissue that render healing more difficult.13,20 Therefore, these changes should be taken into account when treating these patients, although the treatment principles are basically the same as those for young and middle-age patients.13,20 In conclusion, maxillofacial fractures in the elderly have been increasing and showed characteristic features in their etiology, patterns, and treatment modalities. Understanding these characteristics could help to promote clinical research to develop more effective treatment and possibly prevent injuries.
References 1. Iida S, Kogo M, Sugiura T, Mima T, Matsuya T: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30:286, 2001 2. Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 2003 3. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:166, 2004 4. Erol B, Tanrikulu R, Görgün B: Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 32:308, 2004 5. Ferreira PC, Amarante JM, Silva PN, et al: Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 115:1500, 2005 6. Brasileiro BF, Passeri LA: Epidemiological analysis of maxillofacial fractures in Brasil: A 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:28, 2006 7. Cheema SA, Amin F: Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan. Br J Oral Maxillofac Surg 44:232, 2006 8. Bakardjiev A, Pechalova P: Maxillofacial fractures in Southern Bulgaria—A retrospective study of 1706 cases. J Craniomaxillofac Surg 35:147, 2007 9. Erdmann D, Follmar KE, DeBruijn M, et al: A retrospective analysis of facial fracture etiologies. Ann Plast Surg 60:398, 2008 10. Lee JH, Cho BK, Park WJ: A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg 38:192, 2010 11. Falcone PA, Haedicke GJ, Brooks G, Sullivan PK: Maxillofacial fractures in the elderly: A comparative study. Plast Reconstr Surg 86:443, 1990 12. Goldschmidt MJ, Castiglione CL, Assael LA, Litt MD: Craniomaxillofacial trauma in the elderly. J Oral Maxillofac Surg 53: 1145, 1995
2210 13. Gerbino G, Roccia F, De Gioanni PP, Berrone S: Maxillofacial trauma in the elderly. J Oral Maxillofac Surg 57:777, 1999 14. Rehman K, Edmondson H: The cause and consequences of maxillofacial injuries in elderly people. Gerodontology 19:60, 2002 15. Fasola AO, Obiechina AE, Arotiba JT: Incidence and pattern of maxillofacial fractures in the elderly. Int J Oral Maxillofac Surg 32:206, 2003 16. Sidal T, Curtis DA: Fractures of the mandible in the aging population. Spec Care Dentist 26:145, 2006 17. Kloss FR, Tuli T, Hächl O, et al: The impact of aging on craniomaxillofacial trauma—A comparative investigation. Int J Oral Maxillofac Surg 36:1158, 2007 18. Subhashraj K, Ravindran C: Maxillofacial intervention in trauma patients aged 60 years and older. Indian J Dent Res 19:109, 2008 19. Royan SJ, Hamid AL, Kovilpillai FJ, Junid NZ, Mustafa WM: A prospective study on elderly patients with facial fractures in a developing country. Gerodontology 25:124, 2008 20. Chrcanovic BR, Souza LN, Freire-Maua B, et al: Facial fractures in the elderly: A retrospective study in a hospital in Belo Horizonte, Brazil. J Trauma 69:E73, 2010 21. Santora TA, Schinco MA, Trooskin SZ: Management of trauma in the elderly patient. Surg Clin North Am 74:163, 1994 22. Wade CV, Hoffmsn GR, Brennan PA: Falls in elderly people that result in facial injuries. Br J Oral Maxillofac Surg 42:138, 2004
MAXILLOFACIAL FRACTURES IN OLDER PATIENTS 23. Bagheri SC, Dierks EJ, Kademani D, et al: Application of a facial injury severity sale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64:408, 2006 24. Werning JW, Downey NM, Brinker RA, et al: The impact of osteoporosis on patients with maxillofacial trauma. Arch Otolaryngol Head Neck Surg 130:353, 2004 25. Yamamoto K, Kuraki M, Kurihara M, et al: Maxillofacial fractures resulting from falls. J Oral Maxillofac Surg 58:1602, 2010 26. Amaratunga NA, de S: A comparative study of the clinical aspects of edentulous and dentulous mandibular fractures. J Oral Maxillofac Surg 46:3, 1988 27. Down KE, Boot DA, Gorman DF: Maxillofacial and associated injuries in severely traumatized patients: Implications of a regional survey. Int J Oral Maxillofac Surg 24:409, 1995 28. Tung T-C, Tseng W-S, Chen C-T, Lai JP, Chen YR: Acute lifethreatening injuries in facial fracture patients: A review of 1025 patients. J Trauma 49:420, 2000 29. Alvi A, Doherty T, Lewen G: Facial fractures and concomitant injuries in trauma patients. Laryngoscope 113:102, 2003 30. Thorén H, Snäll J, Salo J, et al: Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 68:805, 2010 31. van der Sluis CK, Klasen HJ, Eisma WH, ten Duis HJ: Major trauma in young and old. What is the difference? J Trauma 40:78, 1996