| Abstract|| |
Degloving injuries of the oral cavity are characterised by separation of periosteum and soft tissue of the anterior floor of the mouth from the inner cortex of the anterior segment. The higher incidence of the degloving injuries of mandible are seen in children and young adults due to higher involvement in contact sports. In elders, degloving injury of mandible are rare as compared to that of the limbs which are common. Here, we describe the case report of an elderly female with an apparent soft tissue abrasion with encrustation along the left side of the lower lip due to fall. Thorough intra oral examination revealed the presence of degloving injury along the lower anterior region of mandible which was debrided and sutured. Without a high level of suspicion, such lesions existing in the gingivobuccal sulcus may be missed, leading to increased risk of secondary infection and obligate healing in turn leading to increased morbidity.
Keywords: Case report, degloving, elderly, falls, misdiagnosis
|How to cite this article:|
Lakshminarayan N, Savithramma R B, Bhuvaneshwari N G, Lawrence D. Degloving injury of the mandible among different age groups. Indian J Dent Res 2020;31:149-52
|How to cite this URL:|
Lakshminarayan N, Savithramma R B, Bhuvaneshwari N G, Lawrence D. Degloving injury of the mandible among different age groups. Indian J Dent Res [serial online] 2020 [cited 2021 May 10];31:149-52. Available from: https://www.ijdr.in/text.asp?2020/31/1/149/281795
| Introduction|| |
Falls are prominent among the external causes of unintentional injury. The proportion of elderly in the society increases and fall frequency increases with advancing age. Many falls result in fractures and also soft tissue injuries, longstanding pain, functional impairment, reduced quality of life, increased mortality and excess in healthcare costs. In degloving injuries, external forces shear the skin from the underlying tissues – usually in a tissue plane between the subcutaneous fat and deep fascia. Less severe, though more common, is the degloving injury seen in elderly patients over their limbs, who strike their legs against a low object such as a table or a bus platform. The skin is degloved between the fixed obstacle and the moving limb. Traumatic degloving injuries of the mandible are rare intraoral soft tissue traumas, and can also be seen as parallels in elective orthognathic surgery. In the oral cavity, the oral mucosa in particular the gingivobuccal sulcus is capable of obscuring the injury due to its existence as a natural crease. Traumatic degloving of the lower jaw may involve the outer cortex leading to the separation of the soft tissue mask from the outer surface of the symphysis and parasymphysis, after trauma. Degloving injuries have been previously reported as frequently seen in children. We present a case of degloving injury of mandible seen in elderly female due to fall.
| Case History|| |
A 72-year-old female patient presented to the department of Public Health Dentistry having sustained trauma to the maxillofacial region after a fall at home the previous day. The patient visited the Peripheral Health Centre (PHC) near her home (Bilichodu) on the same day, and was given first aid treatment and medications. The patient visited the department on the second day after trauma and consent was obtained. On examination, the patient was oriented to time, place and person. On extra oral examination of the patient, small lacerations with ecchymosis was evident near corner of left side of chin and lip. Brownish crust with yellowish white serous discharge was seen [Figure 1]. Swelling was evident along left corner of lip. On examination of temporomandibular joint, preauricular tenderness was evident and also tenderness over left chin on palpation.
Intraoral examination revealed a solitary swelling approximately 2 × 2 cm, with a smooth surface and bony hard consistency, along left labial mucosa in relation to left anterior front tooth. The swelling obliterated the mandibular labial sulcus which could be misdiagnosed as infectious lesion [Figure 2]. Thorough examination revealed the presence of teeth 32 and 33 covered by labial mucosa suggestive of a degloving injury secondary to trauma [Figure 3]. The soft tissue injury consisted of a superficial and deep component that were separated by a thin and incomplete fascial compartment. Other findings include several missing teeth, few grossly decayed teeth and generalized microdontia [Figure 4]. Both maxillary and mandibular arches were palpated to check for any evidence of fracture. The orthopantomogram was taken to rule out any fractures, which revealed the presence of teeth 32 and 33, and no evidence of fractures seen radiographicaly [Figure 4]. After the administration of local anesthesia (lidocaine 2% with epinephrine 1/80000), debridement of the injured area and copious irrigation with normal saline and betadine was done. The area was sutured by non-resorbable suture material in layered fashion. Broad spectrum Antibiotics (Tab Amoxclav 650 mg) and Analgesics (Tab Ibuprofen 400 mg) were prescribed for five and three days respectively. Additionally, proper manner of tooth brushing and instructions for wound care was emphasized to the patient. The patient was called up for follow-up after a week and suture removal was done and the mucosa was healing. The patient reported after six weeks [Figure 5] and at two months [Figure 6] and [Figure 7] for further follow and found to have a well-healed gingivobuccal sulcus without the evidence of pocketing or gross deformity.
| Discussion|| |
Traumatic degloving injuries of the mandible are rare intraoral soft tissue traumas. Usually, mandibular degloving injuries take place due to falls, and sport injuries, like skiing and biking. The frequency of falls increases with age and frailty level. Approximately 28-35% of people aged 65 and above fall each year increasing to 32-42% for those over 70 years of age. A study done by Thompson et al. stated that general increase in the contribution of falls relates to the occurrence of dental trauma, with highest dental trauma rate among males aged 65-74 years and facial trauma rate among females aged 85 years and above. The physical and mental changes associated with advancing age and frailty increase the risk of fall-related injury. In elderly patients with thin fragile skin, making it more vulnerable to degloving injury. The patient presented in this case was 72 years old female, perhaps making her vulnerable to such injury. Morbidity caused by such injuries will be prolonged if the injury is not recognized in a timely fashion, because of the age related delayed wound healing. Early identification and prompt treatment by preserving the mucosal remnants by suturing are must for such injuries.
A review of the literature revealed cases of degloving injury most common in upper and lower extremities, but few cases of mandibular degloving have been reported.,5, Moreover, the highest incidence of mandibular degloving injuries is reported in children and young adults. Also, no article till date has reported the prevalence of the degloving injuries of the mandible among elderly. However, no isolated mandibular degloving injuries have been reported in elders. Although more common in pediatric and adolescents, also can be seen among elderly people as in present case. Therefore, the present case is a rarity in two ways. First, for it to appear in this age. Second, degloving in the oral cavity in other cases was easy to identify unlike in the current case where the chances of misdiagnosis was high. Also, here the patient reported to hospital the next day of trauma without superadded infection, which would have facilitated healing by primary intention. Studies reported showed delayed healing and sometimes accompanied by scar formation, due to late reporting., Potential complications of missed or delayed diagnosis include secondary infections leading to dead space formation thereby acting as areas of food lodgment and infection. A course of antibiotics minimizes the risk of infection, swelling and osteomyelitis, but dose has to be minimized because of reduced physiological reserve, impaired homeostasis and immunological system in elderly people.
| Conclusion|| |
The degloving injury exists along the natural line of the deepest part of the lower labial sulcus, which is not commonly examined, that suggests the need for thorough examination of patients reporting with trauma. In conclusion, there is a need for increased knowledge regarding the diagnosis and management of degloving injuries among the elderly, so as to improve their quality of life. The guidelines of CARE checklist was considered for writing the case report.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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N G Bhuvaneshwari
Post Graduate Student, Room No 8, Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]