Treatment decision‐making for a post‐traumatic malocclusion in an elderly patient: A case report.

Abstract Traumatic dental injuries in elderly patients are a rising trend due to demographic and social changes of the population. Older dentulous patients in good health have become increasingly common. The development of a post‐traumatic malocclusion is a common sequela resulting from mandibular condyle fracture, as in the case reported in this paper. The decision‐making process led the authors to rule out conservative treatment options and to perform orthognathic surgery on an 81‐year‐old patient, an unprecedented report in the literature. At one‐year follow‐up, prophylactic therapy, a specific surgical technique, and osteotomy fixation have restored the occlusion to the pre‐traumatic condition.

The physical examination, conducted 10 months after the trauma, showed dentulous upper and lower arches, post-traumatic malocclusion with an increased overjet, and a slight anterior open bite without restrictions in the mandibular range of motion ( Figure 1). The patient reported mild discomfort during mastication but no pain.
Given his characteristics of being elderly and almost fully dentulous, the patient was initially referred to his dentist for occlusal equilibration therapy. However, given its complexity due to the significant loss of mandible height, which would have implied extensive molar grinding, the dentist advised the patient against such treatment. In addition, occlusal equilibration would have not managed the mandibular retrusion and would not have restored the pretrauma occlusion.
Since the patient strongly demanded treatment to address the retruded appearance of his mandible, surgical correction of the malocclusion with orthognathic surgery involving the lower jaw was suggested. An orthopantogram and a lateral cephalogram of the patient were obtained. Standard model planning was done, and supplemental calcium and vitamin D therapy were prescribed, starting from ten days prior to the surgical intervention.
A bilateral sagittal split osteotomy (BSSO) was performed to advance and rotate the mandible in order to restore the occlusion. Intermaxillary fixation (IMF) was accomplished with both tooth-and bone-borne appliances. Spino-mental fixation was applied with two trans-mucosally inserted self-drilling screws. Two S-shaped wire hooks were attached to the central IMF screws (Figure 2), and two IMF screws were applied on the left side. On the right side, fixation was achieved with an IMF screw in the mandibular bone and with a wire ligature on a maxillary premolar. A single 2.3 plate was applied to each mandibular side for internal fixation.
Spino-mental hooks were left in place after the surgery for potential elastic fixation, in order to provide occlusal guidance and to lighten the condylar load consequent to mandibular advancement and rotation, thus avoiding condylar resorption ( Figure 3). Besides persistent cervical bruising, there were no major post-operative complications and the patient was discharged from the hospital three days after the surgery. A non-steroidal anti-inflammatory drug was prescribed, along with continuing the supplemental calcium and vitamin D therapy for 2 months. Follow-up visits were scheduled up to 1 year after intervention. The spino-mental screws were removed after two weeks. No further dental or prosthetic treatments were needed, and the occlusion remained stable over time ( Figure 4). factory results of closed treatments, and the functional rather than esthetic goals make non-surgical treatment more frequent among geriatric patients, 9 as recently reported by a European multicenter study. 10 Regardless of whether the initial choice is an open or closed treatment, condylar fractures are burdened with a significant rate of unsuccessful outcomes as in the presented case. Successful treatment in condylar fractures depends on the biological characteristics and adaptive capability of the patient's masticatory system, which differs between elderly and younger individuals. The elderly's lack of sound biology and adaptation can lead to an unfavorable outcome even with good treatment, especially in cases with bilateral fractures which require a more extensive adaptation. 11 Malocclusion is one of the most common complications after treating patients with condylar fractures, with an incidence ranging from 1.4% to 13.5% of cases. 12,13 One of the most significative factors for such a complication is the degree of mandibular ramus deformity. Many treatment strategies are available depending on the severity, the location and age of the fracture, and on the patient characteristics. The goals of therapy, regardless of the type of treatment, are the achievement of a stable occlusion, and regular mandibular function and shape. Mandibular ramus and temporomandibular joint (TMJ) conditions are the most important variables to consider when choosing the secondary treatment: Cases with severe ramus shortening or fragmentation, or with poor TMJ function due to ankylotic, necrotic, or resorptive processes, are best managed with TMJ reconstruction surgery, although it is a less frequent scenario. 14  Functional rehabilitation can be an effective therapy in the first months after the initial injury, while TMJ, bony and soft tissue remodeling processes are still occurring. 15 After about three months, it is uncommon to achieve a successful outcome using functional therapy. In such cases, it is crucial to take into account the type of fracture, and the patient's concerns and biological characteristics. In the literature, the few studies that focus on the outcome of orthognathic procedures on elderly patients yield mixed reports.

| DISCUSS ION
August et al., 21 Ylikontiola et al., 22 and Parton et al. 23 reported an age-related increased incidence of postoperative neurosensory disturbance. Peacock et al. found an average longer hospitalization time and increased likelihood of hardware removal in patients older than 40 years compared to a younger group. 24 Kriwalsky et al. showed that older patients were more at risk of a bad split than the younger ones. 25 Conversely, Sloane et al. found no significative differences in the outcome between a group of patients older than 35 and a group of younger patients. 26 28 The patient's post-operative period did not differ significantly from the usual post-operative period of younger patients.

| CON CLUS IONS
The present case discusses the therapeutic alternatives in an 81-year-old patient with a post-traumatic malocclusion with preserved TMJ function.

CO N FLI C T O F I NTE R E S T
None.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analyzed in this study.