Mandibular fractures in aged patients – Challenges in diagnosis

Abstract Background/Aims Delayed treatment of a mandibular fracture can lead to complications. Therefore, early diagnosis is important. The aim of this study was to clarify the specific features of mandibular fractures in aged patients and the effect of age on possible missed diagnoses. Material and Methods Patients aged over 60 years with a recent mandibular fracture were included in the study. The outcome variable was a missed mandibular fracture during the patient's first assessment in the primary health care facility. Predictor variables were age group, categorized as older adults (aged ≥60 and <80 years), elders (aged >80 years), patient's age as a continuous variable and age sub‐group divided into decades. Additional predictor variables were the patient's memory disease and injury associated with intracranial injury. Explanatory variables were gender, injury mechanism, type of mandibular facture, combined other facial fracture, edentulous mandible/maxilla/both, surgical treatment of the mandibular fracture, and scene of injury. Results Mandibular fractures were missed in 20.0% of the 135 patients during their first healthcare assessment. Significant associations between missed fractures and age group, gender, fracture type, or injury mechanism were not found. By contrast, memory disorder (p = .02) and site of injury (p = .02) were significantly associated with missed fractures. Fractures were missed more frequently in patients who were in hospital or in a nursing home at the time of injury. Conclusions There is an increased risk of undiagnosed mandibular fractures in the aged population. Small injury force accidents may cause fractures in old and fragile individuals. Careful examination is necessary, especially in patients with memory disorder.

With age, the risk of several diseases, such as osteoporosis, cardiovascular diseases, memory disorders, and cerebrovascular disorders, increases. [5][6][7][8][9] In addition, balance, muscle strength, and posture control deteriorate and reflexes slow down in older people. 10,11 Memory disorders increase the risk of falling by each point of lowered MINI-MENTAL State Examination (MMSE) results from 30 to 22 with a rate ratio of 1:20. 12 Bones may become brittle 13 and teeth may be lost, leading to lowered alveolar bone volume in the mandible. 14 Age-induced cognitive impairment 15 and memory disorders can lead to difficulties in reporting the injury event or symptoms, causing diagnostic difficulties. Delayed treatment can result in complications such as infection, prolonged pain, numbness, malocclusion, 16,17 and malnutrion, thus potentially causing a collapse in the patient's general health. 18 Previous studies have shown that mandibular fractures can be challenging to diagnose especially in young children, 19 while the number of facial fractures increases in older age groups. 20 The aim of this study was to clarify the specific features of mandibular fractures in patients aged over 60 years. A particular aim was to clarify the possible effect of aging on the diagnostic accuracy of mandibular fractures. The hypothesis was that predisposing factors for missed fractures can be found.

| MATERIAL S AND ME THODS
The internal review board of the Head and Neck Center of Helsinki University Hospital approved the study protocol (HUS/356/2017).
The records of all patients over 60 years diagnosed with a recent mandibular fracture at the Emergency Unit of Oral and Maxillofacial Surgery at Helsinki University Hospital between January 1, 2013 and December 31, 2018 were included. All injury-related patient records were retrieved retrospectively from electronic patient records.
The outcome variable was a missed mandibular fracture. A missed fracture was determined when a fracture was not suspected or diagnosed during the patient's first primary healthcare assessment.
The primary predictor variable was the age group, categorized as older adults (aged ≥60 and <80 years) and elders (aged >80 years).
The secondary predictor variable was the patient's age as a continuous variable and the age sub-group divided into decades. Additional predictor variables were the patient's memory disease and any injury associated with an intracranial injury.
Explanatory variables were gender, injury mechanism, type of mandibular facture, combined other facial fracture, edentulous mandible/maxilla/both, surgical treatment of the mandibular fracture, and scene of injury. Injury mechanisms were grouped into the fol- The other variables were clinical symptoms and findings categorized as skin wounds and contusions, mucosal wounds, pain, swelling of the face, bruise in the facial area, change in occlusion, neurosensory disturbance, restricted mouth opening, dental injury, and bleeding from the ear. Associations between clinical symptoms and findings and missed diagnoses were evaluated. In addition, the number of days from injury to fracture diagnosis and the association between delayed assessment and missed diagnosis were reported.
Data were analyzed using GraphPad Prism version 5.00 (GraphPad Inc.). A two-tailed Mann-Whitney test was used to assess the significance of differences in continuous variables. Fisher's exact test was applied to examine the association between variables with nominal scales. p values of less than .05 were considered significant.

| RE SULTS
A total of 135 patients with mandibular fractures were included in the study. The age of the patients ranged from 60.6 to 94.2 years (mean 73.7 years, median 72.9 years). In all, 76.3% (103) were older adults and the remaining 32 patients (24.7%) were elders ( Table 1).
Just over half were women (56.3%). The most common injury mechanism was a ground-level fall (82.2%), followed by a bicycle accident (5.2%) and traffic accident (3.7%). The most common mandibular fracture type was an isolated unilateral mandibular condyle or ramus fracture (57.8%), and most of the fractures were not associated with other fractures of the facial area (83.0%; Table 2).
The associations between study variables and age groups are presented in Table 2. Fractures of 27 patients (20.0%) were missed at the first healthcare examination. In these patients, the fracture was diagnosed a mean of 11 days after the injury, whereas in patients without a missed fracture, the diagnosis was made on the day of injury ( Table 3). Interestingly, 45.4% of patients with a missed diagnosis were admitted to hospital or lived in a nursing home at the time of injury.

TA B L E 1
By comparison, 90% of patients with a correct diagnosis at the first healthcare contact lived at home (p = .03; Table 2).
An average of 3.6 different symptoms or clinical findings were observed in the patients. The most common clinical finding or symptom was pain, followed by a skin wound on the lower face and restricted mouth opening ( Table 4). No significant differences were present for symptoms or clinical findings in patients with missed fractures and patients whose fracture was suspected/diagnosed at the first healthcare contact.

| DISCUSS ION
This study evaluated the specific features of mandibular fractures in elderly patients aged 60 years or more. The specific aim was to clarify the possible effect of age on missed diagnosis. The hypothesis was that predisposing factors for missed fractures would be found.
This hypothesis was confirmed, as 20.0% of the mandibular fractures were not diagnosed at the first healthcare contact. Significant predictive factors for missed fractures were the patient's memory disorder (p = .02) and the scene of injury (p = .03). The fracture was  A ground-level fall has been reported to be the most common to fall injuries and consider them to be habitual and minor.

TA B L E 4 Associations between clinical findings and symptoms in 135 patients with mandibular fracture
With age, the risk of accidents increases due to age-related changes in balance, muscle strength, posture control, reflexes, and many other common diseases. 10,11,13 In the mandibular region, tooth F I G U R E 1 A 63-year-old woman with no diagnosed diseases or medications visited emergency care the same day after falling on the ground. The patient was examined at the hospital emergency polyclinic, and the skin wound on the anterior lower jaw was sutured. Despite pain in the jaw, the patient did not seek further emergency services until 2 weeks later when the skin had become red and swollen, and the edges of the wound were infected. During the second evaluation, a sub-mental abscess was detected. The patient was referred to an ear, nose, and throat clinic, from which she was referred onward to maxillofacial surgery care. Clinical examination raised suspicion of a mandibular fracture. Dental panoramic tomography showed bilateral mandibular condyle fractures and suspicion of a symphyseal fracture (arrows).

F I G U R E 2
Computer tomography confirmed the diagnosis of a symphyseal fracture (arrow)

F I G U R E 3
The patient underwent surgery for the sub-mental abscess and the fractures. The symphysis fracture was repositioned and fixated with titanium plates and screws, and residual teeth were removed 14 days after the injury.
loss may lead to lowered alveolar bone volume. 14 The atrophic mandible is thin and vulnerable to fractures. 14 As shown in an earlier study, tooth loss increases with age. 26 It is also common in nursing home residents. [27][28][29] However, tooth loss did not explain the diagnostic challenges in this study.

FU N D I N G I N FO R M ATI O N
No funding was received for this study.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.