Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e4
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Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases B.-I. Berg a, b, *, P. Juergens a, b, Y. Soerensen c, M. Savic a, b, H.-F. Zeilhofer a, b, K. Schwenzer-Zimmerer a, b a b c
Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland Krankenhaus Reinbek, Dept. of Surgery (Head: Prof. Dr. T. Strate), Hamburg, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 20 June 2013 Accepted 27 December 2013
Aim: The aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications. Patients and methods: Data for 94 patients (96 cases; aged 80e94 years) with maxillofacial fractures were retrospectively analysed. Results: Data of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma. Conclusion: Facial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach. Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Maxillofacial Elderly Trauma Management Treatment
1. Introduction In industrialised countries, the average age of the population continues to increase. It is predicted that, in 2050, 25% of the American population will be above the age of 65 years. This statistic is also significant in European countries such as Switzerland and Germany, with 11.3% and 14.1%, respectively, of the population being over the age of 85 years (United Nations, 2012). This will total more than 10 million individuals. The incidence of fractures is high in older populations (Piirtola et al., 2008), largely because of agerelated diseases such as osteoporosis. In their lifetime, approximately 30%e50% of women and 15%e30% of men will suffer a fracture related to osteoporosis (Randell et al., 1995). It is accepted that the mandible and maxilla exhibit age-related changes,
* Corresponding author. Department of Cranio-Maxillofacial Surgery, University Hospital, Spitalstrasse 21, 4031 Basel, Switzerland. Tel.: þ41 61 2652525; fax: þ41 61 2657071. E-mail address: [email protected] (B.-I. Berg).
although the influence of osteoporosis is still unclear (Kloss and Gassner, 2006). Furthermore, an increased fracture hazard is present due to sclerosis or osteoporosis of jawbones. Oral and maxillofacial surgery of elderly patients must consider age-related physiological changes of both inner organs and oral structures (Hausamen and Schliephake, 1990). There are few published articles addressing the impact of ageing on maxillofacial trauma in elderly patients (Goldschmidt et al., 1995; Gerbino et al., 1999; Gray et al., 2002; Kloss and Gassner, 2006; Kloss et al., 2007; Arangio et al., 2012; Velayutham et al., 2013). In our literature search, no primary research article was found that included a statistically sufficient number of patients over the age of 80 years. Therefore, it was the aim of this retrospective study to assess the causes, distribution, co-morbidities and complications of treatment for maxillofacial trauma and fractures in this elderly population. Another aim was to show that satisfactory management and preventive strategies can be achieved, thereby significantly improving the quality of life of the elderly population (Hausamen and Schliephake, 1990) affected by maxillofacial trauma.
1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.12.007
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
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B.-I. Berg et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e4
2. Material and methods We retrospectively analysed data for all patients over the age of 80 years requiring treatment for cranio-maxillofacial trauma injuries at the Department of Cranio-maxillofacial and Oral Surgery at the Medical University Hospital of Basel from period 1999 to 2009. Relevant information and data were obtained from clinical records, files and radiological images. This information included sex, age, survival time, diagnosis, localization, surgical intervention (e.g. operating time, surgical access, etc.), aetiology, concomitant injuries (e.g. fractures at different sites, laceration wounds), co-morbidities (e.g. hypertonia, diabetes mellitus, carcinoma, etc.) and complications (e.g. retrobulbar haematoma, ectropion, infections, etc.) during the follow-up period and survival time after trauma. The minimum age of 80 years and above was based on the UN World Population Prospects in which one of the possible “selection variables” is: population 80 plus (United Nations, 2012). Statistical analysis was performed using Excel (Windows Microsoft 2007) and SPSS (Version 11.0, SPSS Inc.). The study was conducted according to the tenets of the Declaration of Helsinki and was approved by the local ethics committee. 3. Results 94 patients with 96 separate incidences of trauma were analysed. Of these, 68% were females and 32% were males. Patient age ranged from 80.25 to 94.67 years, with an average age of 85.21 years. The annual distribution showed an increased number of patients suffering from oral and maxillofacial trauma during the period of 2005e2009 (Fig. 1). The monthly distribution showed a small peak of cases during the summer (Fig. 2). More than 90% of the patients reported for treatment within 48 h of their accident, with 75% of these being treated on the same day. The average follow-up time was determined from 90 patients. Fifty-six patients (48.3%) were still alive at the time of data acquisition. The average follow-up time was 2.41 years, with a minimum of 0.08 years and a maximum of 10.67 years. The follow-up time dictated by death of the patient was 0.23 years on an average, with a minimum of 0.003 years (one day) and a maximum of 7.42 years. Of the 96 fractures, 86 resulted from falls, 9 from traffic accidents and 1 from interpersonal violence. The falls could be categorised as simple falls or stumbling/tripping (n ¼ 65), falling out of bed (n ¼ 4), falling out of a wheelchair (n ¼ 2), falling with a 4wheeled rollator (rolling walker) (n ¼ 1), observed syncopy (n ¼ 3), observed epileptic falls (n ¼ 2) and getting into or out of a bus/tram/car (n ¼ 10). Traffic accidents were categorised as being hit by a tram (n ¼ 3), being a front passenger (n ¼ 2) in a car, being a driver of a car (n ¼ 1), being hit by a car (n ¼ 1), being a motorcyclist (n ¼ 1) and being hit by a motorcycle (n ¼ 1). The fractures were categorised as fractures of the midface (n ¼ 72), mandible (n ¼ 10), midface and mandible (n ¼ 9) and
Fig. 1. Number of patients older than 80 years per year, 1999e2009.
Fig. 2. Monthly distribution of cases.
midface and neurocranium (n ¼ 5). Fractures in the midface included injuries to the zygoma (n ¼ 45), orbital blow-out (n ¼ 18), nasal bone (n ¼ 22), Le Fort I (n ¼ 10), Le Fort II (n ¼ 5) and Le Fort III (n ¼ 3) (more than one choice possible). Mandibular fractures included those to the condylar neck (n ¼ 10), condyle (n ¼ 3), body (n ¼ 4) and parasymphysis (n ¼ 2). In the mandible, fracture lines were identified as single (n ¼ 8), double (n ¼ 3), triple (n ¼ 3) and more than three (n ¼ 1) (more than one choice possible). Dental trauma was recognised in three cases. The first case showed a subluxation of three teeth in the lower jaw, the second case a subluxation of two teeth and one coronal fracture in the upper jaw and the third case had tooth fracture in both jaws. Facial laceration also occurred in 59 cases. In 29 cases, concomitant fractures occurred, the distribution of which is illustrated in Fig. 3. Further concomitant injuries were cerebral contusions in 26 cases and intracranial bleeding in eight cases. Fifty-five patients received surgical intervention in the craniomaxillofacial area. Overall, more female patients (n ¼ 37) underwent surgery, but intra-gender distribution was almost equal (Fig. 4). The surgical approach to the treatment of orbital fractures was a mid-eyelid incision (n ¼ 25), except in one case, where a transconjunctival approach was used. The average operating time for surgical interventions under general anaesthesia was 105 min, with a minimum time of 11 min and a maximum of 360 min. In some cases (n ¼ 14), another, independent, surgical procedure was required, either on the same day or on a different day. This operating time was not included in the numbers mentioned above. Concomitant diseases e generally common in the elderly population e were also found in this study. As far as they were reported, the following organs were affected or the following diseases were found: hypertension (n ¼ 45), heart problems (n ¼ 45), arthritis
Fig. 3. Distribution of concomitant fractures.
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
B.-I. Berg et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e4
Fig. 4. Male and female distribution concerning surgical interventions.
(n ¼ 27), carcinoma (n ¼ 26), dementia (n ¼ 25), intracranial bleeding or insult (n ¼ 25), kidney problems (n ¼ 22), diabetes mellitus (n ¼ 15), lung problems (n ¼ 13), documented osteoporoses (n ¼ 12), back problems (n ¼ 11), gastrointestinal tract problems (n ¼ 10), liver/gall bladder problems (n ¼ 9), thyroid function problems (n ¼ 8), Parkinson’s disease (n ¼ 5), anaemia (n ¼ 8), thrombosis (n ¼ 5) and depression (n ¼ 4). In 39 cases, the intake of oral anticoagulants was documented. Thirty-one patients received acetylsalicylic acid (100 mg), followed by clopidogrel (n ¼ 5) and phenprocoumon (n ¼ 3), or a combination of acetylsalicylic acid (100 mg) and clopidogrel (n ¼ 1). This means that at least 40% of the patients who suffered from a trauma had co-morbidities. Different complications occurred. The aetiology of diplopia (n ¼ 4) was divided into orbital swelling or haematoma (n ¼ 3), the severity of which resolved spontaneously. In one case, due to misfit of the titanium mesh (which resolved following a second surgical procedure), ectropion was still visible at the day of hospital discharge in four patients. One patient needed surgical correction months later. One patient suffered from a permanent blindness in one eye, although a release of the retrobulbar haematoma was initiated without delay. This patient had a history of acetylsalicylic acid intake. Infection of osteosynthesis plates occurred twice. The infection occurred once after 3.3 years in the upper jaw and once after 4.9 years in the lower jaw. In both cases, the osteosynthesis material was removed, and no further complications occurred. Seventy-nine percent of the patients lived at home before the accident occurred, and a third of the patients were discharged to their homes without external rehabilitation. 4. Discussion Whilst falling may seem like a simple event, in reality it is a complex medical issue leading to serious injuries, including facial fractures, lacerations, soft tissue injuries, cranial injuries and even death (Naqvi et al., 2009). Although trauma occurs in every age group, the mechanism of injury varies enormously, and each year the prevalence of patients admitted to hospitals with facial trauma increases (Erol et al., 2004). There are many studies in the literature that have investigated different aspects of trauma in various age groups, but only a few focused primarily on very elderly trauma patients. The age group upon which we focused in our study consisted of octogenarian trauma patients (OTPs) (age 80 years) (Grossman et al., 2003). Different mechanisms can lead to facial trauma in OTPs. In our study, 90% of the patients acquired their fractures due to falls. In comparison with other studies, this is a higher percentage. In the study by Iida et al., of patients over 60 years of age, 70% of the patients were injured by falls (Iida et al., 2003). In the study published by Kloss et al., the mechanism of injury in elderly people was also most frequently a fall (72%) (Kloss et al.,
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2007). Furthermore, the study compared the elderly population (65 years and older) with a large number of traumatic events in the younger population and concluded that the major cause of injuries was accidents at home (37%), followed by sporting accidents (33%). Falls are the sixth leading cause of death in individuals over 65 years (Englander et al., 1996) and the leading cause of death following an accident in the individuals over 75 years (Lilley et al., 1995). A prior fracture is associated with an 86% increased risk of any fracture (Kanis et al., 2004). Risk factors for fractures include the decreases in both bone mass and strength that occur in osteoporosis. The deficit of bone formation, in addition to previous resorption, results in bone loss. Trabeculae disconnected by resorption cavities are probably not repaired (Van Der Linden et al., 2001). Therefore, osteoporosis is characterised by reduced bone mass and disruption of cancellous bone architecture (Croucher et al., 1994). Werning et al. demonstrated that, as the severity of osteoporosis worsened, patients were more likely to sustain a greater number of maxillofacial fractures (p ¼ 0.01) (Werning et al., 2004). It is possible to use an orthopantomogram to screen patients who would be likely to benefit from treatment for osteoporosis. Dental radiographs of the adult population are frequently taken, and in the last four decades, numerous research teams have reported oral radiographic findings associated with osteoporosis. The preponderance of the radiographs shows that the jaws of individuals with osteoporosis show reduced bone mass and altered morphology (White, 2002). A factor which also contributes to the increased risk of fractures in the elderly population is the decrease in coordination of limbs, which can readily be detected by fine motor skills such as, for example, problems with brushing teeth, but also by an increase in falls due to stumbling. Other causes for falls can be related to vascular problems. Very elderly individuals are particularly vulnerable to stroke (Sanossian and Ovbiagele, 2009). In the study by Rehman and Edmondson, five out of 42 patients over the age of 65 had a transient ischaemic attack either at the time of the trauma or one had been previously documented in the medical history (Rehman and Edmondson, 2002). The stroke incidence doubles with every decade after 55 years of age (Dyken et al., 1984); therefore, the high prevalence of stroke in our study is not surprising. There have recently been substantial advances in stroke research, but the very elderly seem to be given fewer vascular protection interventions in comparison with younger counterparts (Sanossian and Ovbiagele, 2009). Another major difference in our study is the male:female ratio of about 1:3. The life expectancy in Europe and America is higher for women than for men, which corresponds to the increased number of women having accidents (Kelsey et al., 2010; United Nations, 2012). Therefore, when we compared results from other papers with our results, we expected a similarly high percentage of women with facial fractures being admitted to hospitals. The female-to-male ratio varied depending on the focus of the paper. In the study by Werning et al., which focused on osteoporosis and its impact in maxillofacial trauma, the distribution was similar to that in our paper (Werning et al., 2004). The paper published by Mijiti et al. found a higher female proportion (31.6%) than male proportion (19.8%) when the cause for the trauma was “falls” (Mijiti et al., 2013), but there are also studies with a higher male ratio (Goldschmidt et al., 1995). The reason for these differences in distribution may be the smaller number of cases (Abdul Rahman et al., 2010) or the different age groups (Gerbino et al., 1999; Naveen Shankar et al., 2012; Kyrgidis et al., 2013). Another study, with a focus on falls (Yamamoto et al., 2010), presented 279 patients, including 163 males and 116 females, with an average age of 51.3 years, who had fallen on a level surface (simple fall). In comparison with our study, the average age was much younger, which might be a possible explanation for the different gender distribution. Concerning the monthly/seasonal distribution of falls, a peak was seen in July and August. In the study
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
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by Eggensperger et al. concerning fractures in individuals in central Switzerland, one of the peak months was also July (Eggensperger et al., 2007). Their study suggested a relation between the increased numbers of fractures and increased alcohol and drug consumption during holidays, but the mean age was only 33 years. The OTPs in our study showed no evidence of elevated alcohol consumption. The study by Rehman and Edmondson investigated patients over the age of 65 and showed opposite results, with a peak incidence of falls during the winter months, particularly in November, December and January (Rehman and Edmondson, 2002). In the OTPs, a documented dental trauma was very rare (3%). These findings are similar to those reported by Kloss et al. and might be related to the degree of edentulism (Kloss et al., 2007). The distribution of fracture location in our study shows a higher percentage of midface fractures compared with mandibular fractures. Rehman and Edmondson found a similar distribution (Rehman and Edmondson, 2002). Mandibular fractures, which occurred in 10% of our cases, were as uncommon as in other studies (Iida et al., 2002; Kloss et al., 2007). Fracture treatment in this retrospective study was chosen depending on the degree of fracture displacement. Salentijn et al. stated that to their knowledge no publications exist in which the absolute indications for surgical treatment of zygomatic complex fractures are described or studied (Salentijn et al., 2013). In our study, the age of the patients and the co-morbidities were of minor importance. In most cases, a computed tomography scan was available for precise radiological diagnostics. The surgical approach was a mid-eyelid incision for orbital fractures, except in one case in which a transconjunctival approach was used. The complications that may arise with this incision include ectropion, entropion and excess scleral show (Nunu et al., 2007). Ectropion was seen as a post-operative complication in four cases in our OTPs, although only one ectropion needed surgical correction. The only other complications concerning the surgical site were in two cases where plates became infected after several years. This complication does not appear to be influenced by age group and can also be found in studies in younger populations (Goldschmidt et al.,1995; Erol et al., 2004). Similarly, this applies to the distribution of concomitant fractures. A comparison should be drawn only between similar age groups because of co-morbidities, which lead to a higher risk. The most common co-morbidity in our study was hypertension (47%). Forty percent of the patients had a documented intake of oral anticoagulants, which increases the risk of larger haematomas that can become infected or cause a retrobulbar haematoma. 5. Conclusion As this study has revealed, the major cause for facial trauma is a fall. Prevention is important due to an increased number of complex medical histories which can complicate management. Elderly people who are involved in sports and daily activities have a consequently lower risk of falling. Our study demonstrates that facial trauma in older people can often be treated conservatively unless the patient complains of functional problems or there is an increased risk of infection. More interdisciplinary studies concerning the prevention of maxillofacial surgery in elderly individuals should be undertaken. References Abdul Rahman N, Ramli R, Abdul Rahman R, Hussaini HM, Abdul Hamid AL: Facial trauma in geriatric patients in a selected Malaysian hospital. Geriatr Gerontol Int 10(1): 64e69, 2010 Arangio P, Leonardi A, Torre U, Bianca C, Cascone P: Management of facial trauma in patients older than 75 years. J Craniofac Surg 23(6): 1690e1692, 2012 Croucher PI, Garrahan NJ, Compston JE: Structural mechanisms of trabecular bone loss in primary osteoporosis: specific disease mechanism or early ageing? Bone Miner 25(2): 111e121, 1994
Dyken ML, Wolf PA, Barnett HJM, Bergan JJ, Hass WK, Kannel WB, et al: Risk factors in stroke. Stroke 15: 1105e1111, 1984 Eggensperger N, Smolka K, Scheidegger B, Zimmermann H, Iizuka T: A 3-year survey of assault-related maxillofacial fractures in central Switzerland. J Craniomaxillofac Surg 35(3): 161e167, 2007 Englander F, Hodson TJ, Terregrossa RA: Economic dimensions of slip and fall injuries. J Forensic Sci 41(5): 733e746, 1996 Erol B, Tanrikulu R, Görgün B: Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 32(5): 308e313, 2004 Gerbino G, Roccia F, De Gioanni PP, Berrone S: Maxillofacial trauma in the elderly. J Oral Maxillofac Surg 57(7): 777e782, 1999 Discussion 782e783 Goldschmidt MJ, Castiglione CL, Assael LA, Litt MD: Craniomaxillofacial trauma in the elderly. J Oral Maxillofac Surg 53(10): 1145e1149, 1995 Gray E, Dierks E, Homer L, Smith F, Potter B: Survey of trauma patients requiring maxillofacial intervention, ages 56 to 91 years, with length of stay analysis. J Oral Maxillofac Surg 60(10): 1114e1125, 2002 Grossman M, Scaff DW, Miller D, Reed 3rd J, Hoey B, Anderson 3rd HL: Functional outcomes in octogenarian trauma. J Trauma 55(1): 26e32, 2003 Hausamen JE, Schliephake H: Oromaxillofacial surgical treatment in ageing patients. Z Gerontol 23(6): 330e337, 1990 Iida S, Hassfeld S, Reuther T, Schweigert HG, Haag C, Klein J, et al: Maxillofacial fractures resulting from falls. J Craniomaxillofac Surg 31(5): 278e283, 2003 Iida S, Reuther T, Kogo M, Matsuya T, Mühling J: Retrospective analysis of facial fractures related to falls in 260 Japanese patients. Mund Kiefer Gesichtschir 6(6): 421e426, 2002 Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, et al: A metaanalysis of previous fracture and subsequent fracture risk. Bone 35(2): 375e 382, 2004 Kelsey JL, Berry SD, Procter-Gray E, Quach L, Nguyen US, Li W, et al: Indoor and outdoor falls in older adults are different: the maintenance of balance, independent living, intellect, and zest in the Elderly of Boston Study. J Am Geriatr Soc 58(11): 2135e2141, 2010 Kloss FR, Gassner R: Bone and ageing: effects on the maxillofacial skeleton. Exp Gerontol 41(2): 123e129, 2006 Kloss FR, Tuli T, Hächl O, Laimer K, Jank S, Stempfl K, et al: The impact of ageing on cranio-maxillofacial trauma-a comparative investigation. Int J Oral Maxillofac Surg 36(12): 1158e1163, 2007 Kyrgidis A, Koloutsos G, Kommata A, Lazarides N, Antoniades K: Incidence, aetiology, treatment outcome and complications of maxillofacial fractures. A retrospective study from Northern Greece. J Craniomaxillofac Surg. http:// dx.doi.org/10.1016/j.jcms.2012.11.046, 2013 Lilley JM, Arie T, Chilvers CED: Special review: accidents involving older people: a review of the literature. Age Ageing 24(4): 346e365, 1995 Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, et al: Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: a 5-year retrospective study. J Craniomaxillofac Surg. http://dx.doi.org/ 10.1016/j.jcms.2013.05.005, 2013 Naqvi F, Lee S, Fields SD: Appraising a guideline for preventing acute care falls. Geriatrics 64(3): 10e13, 2009 26 Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R: The pattern of the maxillofacial fractures e a multicentre retrospective study. J Craniomaxillofac Surg 40(8): 675e679, 2012 Nunu YH, Bell A, McHugh S, Moos KF, Ayoub AF: 3D assessment of morbidity associated with lower eyelid incisions in orbital trauma. Int J Oral Maxillofac Surg 36(8): 680e686, 2007 Piirtola M, Vahlberg T, Isoaho R, Aarnio P, Kivelä SL: Predictors of fractures among the aged: a population-based study with 12-year follow-up in a Finnish municipality. Aging Clin Exp Res 20(3): 242e252, 2008 Randell A, Sambrook PN, Nguyen TV, Lapsley H, Jones G, Kelly PJ, et al: Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 5(6): 427e432, 1995 Rehman K, Edmondson H: The causes and consequences of maxillofacial injuries in elderly people. Gerodontology 19(1): 60e64, 2002 Salentijn EG, Boverhoff J, Heymans MW, van den Bergh B, Forouzanfar T: The clinical and radiographical characteristics of zygomatic complex fractures: a comparison between the surgically and non-surgically treated patients. J Craniomaxillofac Surg. http://dx.doi.org/10.1016/j.jcms.2013.06.008, 2013 Sanossian N, Ovbiagele B: Prevention and management of stroke in very elderly patients. Lancet Neurol 8(11): 1031e1041, 2009 United Nations: World Population Prospects; the 2008 Revision Population Database, http://esa.un.org/unpp/p2k0data.asp; 2012 Van Der Linden JC, Verhaar JA, Weinans H: A three-dimensional simulation of agerelated remodelling in trabecular bone. J Bone Miner Res 16(4): 688e696, 2001 Velayutham L, Sivanandarajasingam A, O’Meara C, Hyam D: Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unit’s workload. Br J Oral Maxillofac Surg 51(2): 128e132, 2013 Werning JW, Downey NM, Brinker RA, Khuder SA, Davis WJ, Rubin AM, et al: The impact of osteoporosis on patients with maxillofacial trauma. Arch Otolaryngol Head Neck Surg 130(3): 353e356, 2004 White SC: Oral radiographic predictors of osteoporosis. Dentomaxillofac Radiol 31(2): 84e92, 2002 Yamamoto K, Kuraki M, Kurihara M, Matsusue Y, Murakami K, Horita S, et al: Maxillofacial fractures resulting from falls. J Oral Maxillofac Surg 68(7): 1602e 1607, 2010
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases B.-I. Berg a, b, *, P. Juergens a, b, Y. Soerensen c, M. Savic a, b, H.-F. Zeilhofer a, b, K. Schwenzer-Zimmerer a, b a b c
Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland Krankenhaus Reinbek, Dept. of Surgery (Head: Prof. Dr. T. Strate), Hamburg, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 20 June 2013 Accepted 27 December 2013
Aim: The aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications. Patients and methods: Data for 94 patients (96 cases; aged 80e94 years) with maxillofacial fractures were retrospectively analysed. Results: Data of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma. Conclusion: Facial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach. Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Maxillofacial Elderly Trauma Management Treatment
1. Introduction In industrialised countries, the average age of the population continues to increase. It is predicted that, in 2050, 25% of the American population will be above the age of 65 years. This statistic is also significant in European countries such as Switzerland and Germany, with 11.3% and 14.1%, respectively, of the population being over the age of 85 years (United Nations, 2012). This will total more than 10 million individuals. The incidence of fractures is high in older populations (Piirtola et al., 2008), largely because of agerelated diseases such as osteoporosis. In their lifetime, approximately 30%e50% of women and 15%e30% of men will suffer a fracture related to osteoporosis (Randell et al., 1995). It is accepted that the mandible and maxilla exhibit age-related changes,
* Corresponding author. Department of Cranio-Maxillofacial Surgery, University Hospital, Spitalstrasse 21, 4031 Basel, Switzerland. Tel.: þ41 61 2652525; fax: þ41 61 2657071. E-mail address: [email protected] (B.-I. Berg).
although the influence of osteoporosis is still unclear (Kloss and Gassner, 2006). Furthermore, an increased fracture hazard is present due to sclerosis or osteoporosis of jawbones. Oral and maxillofacial surgery of elderly patients must consider age-related physiological changes of both inner organs and oral structures (Hausamen and Schliephake, 1990). There are few published articles addressing the impact of ageing on maxillofacial trauma in elderly patients (Goldschmidt et al., 1995; Gerbino et al., 1999; Gray et al., 2002; Kloss and Gassner, 2006; Kloss et al., 2007; Arangio et al., 2012; Velayutham et al., 2013). In our literature search, no primary research article was found that included a statistically sufficient number of patients over the age of 80 years. Therefore, it was the aim of this retrospective study to assess the causes, distribution, co-morbidities and complications of treatment for maxillofacial trauma and fractures in this elderly population. Another aim was to show that satisfactory management and preventive strategies can be achieved, thereby significantly improving the quality of life of the elderly population (Hausamen and Schliephake, 1990) affected by maxillofacial trauma.
1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.12.007
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
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2. Material and methods We retrospectively analysed data for all patients over the age of 80 years requiring treatment for cranio-maxillofacial trauma injuries at the Department of Cranio-maxillofacial and Oral Surgery at the Medical University Hospital of Basel from period 1999 to 2009. Relevant information and data were obtained from clinical records, files and radiological images. This information included sex, age, survival time, diagnosis, localization, surgical intervention (e.g. operating time, surgical access, etc.), aetiology, concomitant injuries (e.g. fractures at different sites, laceration wounds), co-morbidities (e.g. hypertonia, diabetes mellitus, carcinoma, etc.) and complications (e.g. retrobulbar haematoma, ectropion, infections, etc.) during the follow-up period and survival time after trauma. The minimum age of 80 years and above was based on the UN World Population Prospects in which one of the possible “selection variables” is: population 80 plus (United Nations, 2012). Statistical analysis was performed using Excel (Windows Microsoft 2007) and SPSS (Version 11.0, SPSS Inc.). The study was conducted according to the tenets of the Declaration of Helsinki and was approved by the local ethics committee. 3. Results 94 patients with 96 separate incidences of trauma were analysed. Of these, 68% were females and 32% were males. Patient age ranged from 80.25 to 94.67 years, with an average age of 85.21 years. The annual distribution showed an increased number of patients suffering from oral and maxillofacial trauma during the period of 2005e2009 (Fig. 1). The monthly distribution showed a small peak of cases during the summer (Fig. 2). More than 90% of the patients reported for treatment within 48 h of their accident, with 75% of these being treated on the same day. The average follow-up time was determined from 90 patients. Fifty-six patients (48.3%) were still alive at the time of data acquisition. The average follow-up time was 2.41 years, with a minimum of 0.08 years and a maximum of 10.67 years. The follow-up time dictated by death of the patient was 0.23 years on an average, with a minimum of 0.003 years (one day) and a maximum of 7.42 years. Of the 96 fractures, 86 resulted from falls, 9 from traffic accidents and 1 from interpersonal violence. The falls could be categorised as simple falls or stumbling/tripping (n ¼ 65), falling out of bed (n ¼ 4), falling out of a wheelchair (n ¼ 2), falling with a 4wheeled rollator (rolling walker) (n ¼ 1), observed syncopy (n ¼ 3), observed epileptic falls (n ¼ 2) and getting into or out of a bus/tram/car (n ¼ 10). Traffic accidents were categorised as being hit by a tram (n ¼ 3), being a front passenger (n ¼ 2) in a car, being a driver of a car (n ¼ 1), being hit by a car (n ¼ 1), being a motorcyclist (n ¼ 1) and being hit by a motorcycle (n ¼ 1). The fractures were categorised as fractures of the midface (n ¼ 72), mandible (n ¼ 10), midface and mandible (n ¼ 9) and
Fig. 1. Number of patients older than 80 years per year, 1999e2009.
Fig. 2. Monthly distribution of cases.
midface and neurocranium (n ¼ 5). Fractures in the midface included injuries to the zygoma (n ¼ 45), orbital blow-out (n ¼ 18), nasal bone (n ¼ 22), Le Fort I (n ¼ 10), Le Fort II (n ¼ 5) and Le Fort III (n ¼ 3) (more than one choice possible). Mandibular fractures included those to the condylar neck (n ¼ 10), condyle (n ¼ 3), body (n ¼ 4) and parasymphysis (n ¼ 2). In the mandible, fracture lines were identified as single (n ¼ 8), double (n ¼ 3), triple (n ¼ 3) and more than three (n ¼ 1) (more than one choice possible). Dental trauma was recognised in three cases. The first case showed a subluxation of three teeth in the lower jaw, the second case a subluxation of two teeth and one coronal fracture in the upper jaw and the third case had tooth fracture in both jaws. Facial laceration also occurred in 59 cases. In 29 cases, concomitant fractures occurred, the distribution of which is illustrated in Fig. 3. Further concomitant injuries were cerebral contusions in 26 cases and intracranial bleeding in eight cases. Fifty-five patients received surgical intervention in the craniomaxillofacial area. Overall, more female patients (n ¼ 37) underwent surgery, but intra-gender distribution was almost equal (Fig. 4). The surgical approach to the treatment of orbital fractures was a mid-eyelid incision (n ¼ 25), except in one case, where a transconjunctival approach was used. The average operating time for surgical interventions under general anaesthesia was 105 min, with a minimum time of 11 min and a maximum of 360 min. In some cases (n ¼ 14), another, independent, surgical procedure was required, either on the same day or on a different day. This operating time was not included in the numbers mentioned above. Concomitant diseases e generally common in the elderly population e were also found in this study. As far as they were reported, the following organs were affected or the following diseases were found: hypertension (n ¼ 45), heart problems (n ¼ 45), arthritis
Fig. 3. Distribution of concomitant fractures.
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
B.-I. Berg et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e4
Fig. 4. Male and female distribution concerning surgical interventions.
(n ¼ 27), carcinoma (n ¼ 26), dementia (n ¼ 25), intracranial bleeding or insult (n ¼ 25), kidney problems (n ¼ 22), diabetes mellitus (n ¼ 15), lung problems (n ¼ 13), documented osteoporoses (n ¼ 12), back problems (n ¼ 11), gastrointestinal tract problems (n ¼ 10), liver/gall bladder problems (n ¼ 9), thyroid function problems (n ¼ 8), Parkinson’s disease (n ¼ 5), anaemia (n ¼ 8), thrombosis (n ¼ 5) and depression (n ¼ 4). In 39 cases, the intake of oral anticoagulants was documented. Thirty-one patients received acetylsalicylic acid (100 mg), followed by clopidogrel (n ¼ 5) and phenprocoumon (n ¼ 3), or a combination of acetylsalicylic acid (100 mg) and clopidogrel (n ¼ 1). This means that at least 40% of the patients who suffered from a trauma had co-morbidities. Different complications occurred. The aetiology of diplopia (n ¼ 4) was divided into orbital swelling or haematoma (n ¼ 3), the severity of which resolved spontaneously. In one case, due to misfit of the titanium mesh (which resolved following a second surgical procedure), ectropion was still visible at the day of hospital discharge in four patients. One patient needed surgical correction months later. One patient suffered from a permanent blindness in one eye, although a release of the retrobulbar haematoma was initiated without delay. This patient had a history of acetylsalicylic acid intake. Infection of osteosynthesis plates occurred twice. The infection occurred once after 3.3 years in the upper jaw and once after 4.9 years in the lower jaw. In both cases, the osteosynthesis material was removed, and no further complications occurred. Seventy-nine percent of the patients lived at home before the accident occurred, and a third of the patients were discharged to their homes without external rehabilitation. 4. Discussion Whilst falling may seem like a simple event, in reality it is a complex medical issue leading to serious injuries, including facial fractures, lacerations, soft tissue injuries, cranial injuries and even death (Naqvi et al., 2009). Although trauma occurs in every age group, the mechanism of injury varies enormously, and each year the prevalence of patients admitted to hospitals with facial trauma increases (Erol et al., 2004). There are many studies in the literature that have investigated different aspects of trauma in various age groups, but only a few focused primarily on very elderly trauma patients. The age group upon which we focused in our study consisted of octogenarian trauma patients (OTPs) (age 80 years) (Grossman et al., 2003). Different mechanisms can lead to facial trauma in OTPs. In our study, 90% of the patients acquired their fractures due to falls. In comparison with other studies, this is a higher percentage. In the study by Iida et al., of patients over 60 years of age, 70% of the patients were injured by falls (Iida et al., 2003). In the study published by Kloss et al., the mechanism of injury in elderly people was also most frequently a fall (72%) (Kloss et al.,
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2007). Furthermore, the study compared the elderly population (65 years and older) with a large number of traumatic events in the younger population and concluded that the major cause of injuries was accidents at home (37%), followed by sporting accidents (33%). Falls are the sixth leading cause of death in individuals over 65 years (Englander et al., 1996) and the leading cause of death following an accident in the individuals over 75 years (Lilley et al., 1995). A prior fracture is associated with an 86% increased risk of any fracture (Kanis et al., 2004). Risk factors for fractures include the decreases in both bone mass and strength that occur in osteoporosis. The deficit of bone formation, in addition to previous resorption, results in bone loss. Trabeculae disconnected by resorption cavities are probably not repaired (Van Der Linden et al., 2001). Therefore, osteoporosis is characterised by reduced bone mass and disruption of cancellous bone architecture (Croucher et al., 1994). Werning et al. demonstrated that, as the severity of osteoporosis worsened, patients were more likely to sustain a greater number of maxillofacial fractures (p ¼ 0.01) (Werning et al., 2004). It is possible to use an orthopantomogram to screen patients who would be likely to benefit from treatment for osteoporosis. Dental radiographs of the adult population are frequently taken, and in the last four decades, numerous research teams have reported oral radiographic findings associated with osteoporosis. The preponderance of the radiographs shows that the jaws of individuals with osteoporosis show reduced bone mass and altered morphology (White, 2002). A factor which also contributes to the increased risk of fractures in the elderly population is the decrease in coordination of limbs, which can readily be detected by fine motor skills such as, for example, problems with brushing teeth, but also by an increase in falls due to stumbling. Other causes for falls can be related to vascular problems. Very elderly individuals are particularly vulnerable to stroke (Sanossian and Ovbiagele, 2009). In the study by Rehman and Edmondson, five out of 42 patients over the age of 65 had a transient ischaemic attack either at the time of the trauma or one had been previously documented in the medical history (Rehman and Edmondson, 2002). The stroke incidence doubles with every decade after 55 years of age (Dyken et al., 1984); therefore, the high prevalence of stroke in our study is not surprising. There have recently been substantial advances in stroke research, but the very elderly seem to be given fewer vascular protection interventions in comparison with younger counterparts (Sanossian and Ovbiagele, 2009). Another major difference in our study is the male:female ratio of about 1:3. The life expectancy in Europe and America is higher for women than for men, which corresponds to the increased number of women having accidents (Kelsey et al., 2010; United Nations, 2012). Therefore, when we compared results from other papers with our results, we expected a similarly high percentage of women with facial fractures being admitted to hospitals. The female-to-male ratio varied depending on the focus of the paper. In the study by Werning et al., which focused on osteoporosis and its impact in maxillofacial trauma, the distribution was similar to that in our paper (Werning et al., 2004). The paper published by Mijiti et al. found a higher female proportion (31.6%) than male proportion (19.8%) when the cause for the trauma was “falls” (Mijiti et al., 2013), but there are also studies with a higher male ratio (Goldschmidt et al., 1995). The reason for these differences in distribution may be the smaller number of cases (Abdul Rahman et al., 2010) or the different age groups (Gerbino et al., 1999; Naveen Shankar et al., 2012; Kyrgidis et al., 2013). Another study, with a focus on falls (Yamamoto et al., 2010), presented 279 patients, including 163 males and 116 females, with an average age of 51.3 years, who had fallen on a level surface (simple fall). In comparison with our study, the average age was much younger, which might be a possible explanation for the different gender distribution. Concerning the monthly/seasonal distribution of falls, a peak was seen in July and August. In the study
Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
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by Eggensperger et al. concerning fractures in individuals in central Switzerland, one of the peak months was also July (Eggensperger et al., 2007). Their study suggested a relation between the increased numbers of fractures and increased alcohol and drug consumption during holidays, but the mean age was only 33 years. The OTPs in our study showed no evidence of elevated alcohol consumption. The study by Rehman and Edmondson investigated patients over the age of 65 and showed opposite results, with a peak incidence of falls during the winter months, particularly in November, December and January (Rehman and Edmondson, 2002). In the OTPs, a documented dental trauma was very rare (3%). These findings are similar to those reported by Kloss et al. and might be related to the degree of edentulism (Kloss et al., 2007). The distribution of fracture location in our study shows a higher percentage of midface fractures compared with mandibular fractures. Rehman and Edmondson found a similar distribution (Rehman and Edmondson, 2002). Mandibular fractures, which occurred in 10% of our cases, were as uncommon as in other studies (Iida et al., 2002; Kloss et al., 2007). Fracture treatment in this retrospective study was chosen depending on the degree of fracture displacement. Salentijn et al. stated that to their knowledge no publications exist in which the absolute indications for surgical treatment of zygomatic complex fractures are described or studied (Salentijn et al., 2013). In our study, the age of the patients and the co-morbidities were of minor importance. In most cases, a computed tomography scan was available for precise radiological diagnostics. The surgical approach was a mid-eyelid incision for orbital fractures, except in one case in which a transconjunctival approach was used. The complications that may arise with this incision include ectropion, entropion and excess scleral show (Nunu et al., 2007). Ectropion was seen as a post-operative complication in four cases in our OTPs, although only one ectropion needed surgical correction. The only other complications concerning the surgical site were in two cases where plates became infected after several years. This complication does not appear to be influenced by age group and can also be found in studies in younger populations (Goldschmidt et al.,1995; Erol et al., 2004). Similarly, this applies to the distribution of concomitant fractures. A comparison should be drawn only between similar age groups because of co-morbidities, which lead to a higher risk. The most common co-morbidity in our study was hypertension (47%). Forty percent of the patients had a documented intake of oral anticoagulants, which increases the risk of larger haematomas that can become infected or cause a retrobulbar haematoma. 5. Conclusion As this study has revealed, the major cause for facial trauma is a fall. Prevention is important due to an increased number of complex medical histories which can complicate management. Elderly people who are involved in sports and daily activities have a consequently lower risk of falling. Our study demonstrates that facial trauma in older people can often be treated conservatively unless the patient complains of functional problems or there is an increased risk of infection. More interdisciplinary studies concerning the prevention of maxillofacial surgery in elderly individuals should be undertaken. References Abdul Rahman N, Ramli R, Abdul Rahman R, Hussaini HM, Abdul Hamid AL: Facial trauma in geriatric patients in a selected Malaysian hospital. Geriatr Gerontol Int 10(1): 64e69, 2010 Arangio P, Leonardi A, Torre U, Bianca C, Cascone P: Management of facial trauma in patients older than 75 years. J Craniofac Surg 23(6): 1690e1692, 2012 Croucher PI, Garrahan NJ, Compston JE: Structural mechanisms of trabecular bone loss in primary osteoporosis: specific disease mechanism or early ageing? Bone Miner 25(2): 111e121, 1994
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Please cite this article in press as: Berg B-I, et al., Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2013.12.007
