Non-gunshot injuries of the maxillofacial region in elderly and elderly persons

Emergency care for elderly and senile patients should be provided by highly qualified maxillofacial surgeons who are able to quickly understand the general condition of the victim and decide on the need for a particular intervention depending on the presence of concomitant diseases: atherosclerosis, diabetes mellitus, cardiosclerosis, arterial hypertension, pulmonary emphysema and other chronic diseases.

This task is further complicated by the fact that it is often very difficult to collect anamnesis from victims of this age, since their memory and self-control are weakened, pain sensitivity and temperature reaction to injury are reduced. All this makes it difficult to establish a diagnosis.

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Symptoms of facial injuries

Reduced reserve and adaptive capabilities, impaired reactivity of the body in elderly and senile victims are caused by age-related changes in the structure and function of cells of organs and systems that regulate metabolic processes, as well as a low level of financial and pension provision. All this affects the clinical symptoms, course and outcome of maxillofacial trauma. For example, with lacerated and contused wounds, extensive hematomas are often observed, caused by a decrease in the elasticity of blood vessels (sclerotic changes) and an increase in their vulnerability.

The peculiarities of the course of injuries to the maxillofacial region in elderly and senile patients also include slow resorption of blood poured under the skin and slow consolidation of jaw fragments due to reduced regenerative capacity of the bone. At the same time, due to the absence of teeth, fractures of the lower jaw may remain closed, since the mucous membrane of the gum with the periosteum peels off relatively easily. In such cases, the fracture is determined (by eye and palpation) as a step-like deformation of the toothless gum. If the closed fracture does not become infected, the patient does not develop such possible complications as traumatic osteomyelitis, abscess or phlegmon in the surrounding tissues.

However, due to the absence of teeth and the bite symptom, it is difficult to diagnose a fracture without radiography if it has not caused significant displacement of the fragments.

When treating jaw fractures in these patients, it is necessary to take into account the presence of concomitant diseases (circulatory, digestive, respiratory, endocrine systems, periodontal, etc.), the absence and instability of existing teeth, the degree of atrophy of the alveolar process and displacement of jaw fragments, the presence of removable dentures in the patient (capable of acting as a splint), the degree of osteosclerosis, the absence of the alveolar process and partial atrophy of the body of the jaw, etc.

Treatment of fractures of the lower jaw

The application of dental wire splints for fractures of the lower jaw in elderly and senile patients is not always possible due to the absence or instability of teeth.

Indications for tooth extraction from a fracture gap in this group of patients should be significantly expanded to prevent infection from being "sucked" into the bone gap from the oral cavity. For example, an absolute indication for tooth extraction from a fracture gap is the presence of periodontitis and pulpitis.

If the displacement of the fragments of the edentulous lower jaw is insignificant (no more than 2-3 mm), and the patient has a removable denture, it can be used as a splint, additionally applying a sufficiently rigid sling-like bandage. To facilitate feeding, the upper and lower dentures can be connected with fast-hardening plastic, and in the incisal zone of this "block" a hole can be drilled with a cutter to facilitate feeding (from a drinking cup, a special spoon).

In this case, there is no need to achieve ideally precise repositioning and fixation of fragments of the edentulous jaw, as in the case of the presence of teeth (for precise restoration of the bite). Inaccuracy in the comparison of edentulous fragments even by 2-3 mm is not of decisive importance for the bite, since it can be leveled during the subsequent manufacture of a removable denture.

If the toothless fragments are displaced by more than 2-3 mm, they can be aligned and held in the correct position using the M. M. Vankevich splint in combination with a sling bandage. If this method is unsuccessful, osteosynthesis is performed, taking into account the following circumstances.

1. In case of atrophy of the alveolar process and part of the body of the jaw against the background of very dense bone tissue (due to sclerosis), it is technically difficult to apply a bone suture and damage to the vascular-nerve bundle is possible during osteosynthesis; therefore, the formation of holes, the application of bone frames or the insertion of a pin must be done with the utmost care.
2. In cases of oblique fracture of the body of the jaw, osteosynthesis using the wrapping suture method should be used.
3. The use of extra-focal (extra-focal) devices for repositioning and compression osteosynthesis in this category of victims is not always possible, since due to the slow consolidation, a longer effect of extra-focal clamps or pins on the compact and spongy parts of the bone is required than in young people; this entails bone resorption under the clamps or around the pins, and their loosening.
4. After applying an immobilizing device (a splint, osteosynthesis in one form or another), it is necessary to stimulate the fusion of jaw fragments, using the recommendations of a therapist, endocrinologist, and neurologist.
5. If the patient has periodontitis, it is preferable to use plastic mouth guards, since wire dental splints and interdental ligatures injure the gums, aggravating the course of periodontitis; its treatment should be carried out in parallel with the treatment of the fracture in order to accelerate consolidation, which slows down in periodontitis due to the presence of dystrophic and inflammatory changes in the area of injury.

Yu. F. Grigorchuk, G. P. Ruzin et al. (1997) developed and successfully tested a combination splint for the treatment of jaw fractures with significant defects in the dental arches in elderly patients.

Treatment of fractures of the upper jaw

For the treatment of upper jaw fractures in elderly and senile patients, plastic splints with extraoral rods - "whiskers" fixed to a plaster cast or a standard cloth or bandage cap can be used. If the victim has an upper removable denture, it can be used as a splint by welding extraoral rods - "whiskers" to it (with quick-hardening plastic) or by connecting this denture to the lower removable denture with the same quick-hardening plastic. Such an improvised Porta splint is supplemented with a chin sling-like bandage.

As for osteosynthesis that suspends the upper jaw (like the Adams, Federspil, T.V. Chernyatina, etc. operations), in my opinion, this type of immobilization should not be used in elderly and senile patients, so as not to cause them additional trauma.