Maxillofacial Gunshot Injuries Research Articles

Long-term Follow-up of Implant Installation Following Multiple Distraction Osteogenesis in Maxillofacial Gunshot Wounds.

Distraction osteogenesis (DO) is a reconstruction technique developed in the fields of oral and maxillofacial surgery and plastic surgery, addressing both vertical and horizontal bone deficiencies and enhancing soft tissue volume to facilitate subsequent dental implant placement. In this treatment method, devices are placed to stretch the bone gradually to stimulate the formation of new bone, effectively filling the existing defect to treat maxillofacial deformities or repair posttraumatic injuries. This case report presents an almost 20-year long-term follow-up of jaw defect reconstruction resulting from a gunshot injury, using DO with multiple distractors. Details on the frequency, period of DO, and subsequent implant installation in the distracted anterior jaw area are outlined. This case exhibits DO treatments that reconstructed effectively severe bone defects in the jaws. The quality of bone generated during the DO process was both functionally and esthetically satisfactory for subsequent implant rehabilitation.

Management of Maxillofacial Gunshot Injuries With Emphasis on Damage Control Surgery During the Yemen Civil War. Review of 173 Victims From a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia.

Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study. The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery. This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp). A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean ± SD (27.5 ± 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims. We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.

Maxillofacial gunshot injuries management in tripoli from 2011–2018

Background: Management of facial gunshot wounds poses a challenge not only for the oral and maxillofacial surgeons but also for the reconstructive surgeons.

Microsurgical reconstruction of complex maxillofacial gunshot wounds: Outcomes analysis and algorithm.

Satisfaction with appearance, functional outcomes (speech, swallowing), work status after microsurgical reconstruction for maxillofacial gunshot wounds (GSW) remain largely unknown. The purpose of this study is to report these parameters. By investigating these outcomes, we also aimed to provide microsurgical algorithms for complex maxillofacial GSW. Forty-two consecutive maxillofacial GSW patients between 2006 and 2014 were analyzed for outcomes. Mean age was 41.3 years ranging 14 to 77 years. There were 33 males and 9 females. Twenty-four patients received 36 free flaps for early reconstruction in 1 to 2 weeks, two patients in a delayed manner. Fifteen fibula flaps for mandible reconstruction, five fibula, there radial forearm (RF), and two scapular osteocutaneous (OC) flaps for maxilla reconstruction, two RF flaps for palate reconstruction, one RF for cheek reconstruction were used. Four patients underwent innervated gracilis flap for total lower lip and one for cheek reconstruction. Rectus abdominis myocutaneous flap was used for mid-face defects in two patients. One anterolateral thigh flap was used for lower lip/chin reconstruction. Nine free flaps were performed to treat a complication and/or to improve function. All flaps survived except for three partial skin paddle loss to fibula flaps. Mean follow-up was 17.2 months. Return to work/school was 70%. Surveys noted 58% "satisfied". All patients but two achieved perceptible speech, the majority had no difficulty with swallowing, all patients had oral competence. Favorable outcomes were obtained in most maxillofacial GSW. After investigating these outcomes, microsurgical algorithms were developed for clinical practice for reconstruction of composite mandible and total-lower lip defects, and maxilla/mid-face defects.

Management of high velocity and high-energy blast Injuries to the maxillofacial region at Nasserr Institute

Management of gunshot injuries to the face remains a cornerstone of the specialty of oral and maxillofacial surgery. Since the events of January 2011, the number of firearm related injuries has increased in Egypt, which was not the case since October 1973; this represented a challenge to both residents and experienced surgeons, owing to the complex nature of these injuries. The major types of gunshot injuries are blasts, either low order or high order explosives, high velocity and low velocity injuries. The severity of the injury depends on velocity, type of bullet and distance, resulting wounds could be penetrating, perforating or avulsive. The timing, sequence and prioritization of treatment remains the main areas of concern in the management of such complex cases. The following is the experience of the Maxillofacial Department at Nasser Institute in management of high velocity and high-energy blast Injuries to the maxillofacial region.18 cases of Maxillofacial gunshot injuries were admitted to Nasserr institute between January 2011 and October 2012 which was a time of street disturbances in Egypt, only nine patients met the criteria of selection suffering from high velocity injuries were included. Upon arrival, all patients underwent a primary survey and extensive clinical and radiographic examination, accordingly a treatment plan was set for each patient and surgical intervention there after according to the protocol we present. Based on our results and treatment outcome for all patients, we conclude that triaging gunshot injuries to a prepared trauma center, following a well-tailored protocol and the use of computer aided surgical simulation is an integral part to perfect the functional and esthetic outcome and treatment.

A Study on Dorsal Pedicled Tongue Flap Closure of Palatal Fistulae and Oronasal Communications.

Introduction:Residual defects of the palatal region following ablative resection of tumors and Gunshot wounds (GSWs) of the maxillofacial region can be quite painstaking, daunting and challenging to reconstruct, due to the extent and composite nature of the tissue loss. A shortage of available donor areas and local flap options in the intraoral region, add to the difficulty. Further compounding the situation, are factors such as excessive fibrosis and scarring of the palatal tissues as a result of multiple previous surgeries in the region.Objective:To evaluate the effectiveness of the Dorsal Pedicled Tongue Flap in the reconstruction of complex palatal defects resulting from maxillofacial GSWs and ablative tumor resections. To also device techniques to reduce the incidence of postoperative tongue flap detachment, thus improving its efficiency and reliability.Results:The palatal fistulas in all the patients were closed successfully, with no post-operative complications such as bleeding, hematoma formation, congestion, infection, partial or total flap necrosis or flap detachment. The tongue flap at the recipient site remained healthy with no recurrence of the fistula in any of the patients in the two years follow up period. There was a complete resolution of the problem of nasal regurgitation of orally ingested fluids and food particles. There was observed no deformity or articulation defect resulting from the flap harvested from the tongue dorsum, in any of the patients.Conclusion:In GSWs and tumor ablative surgery, where composite tissue defects are involved, the tongue provides a reliable and efficient means of restoring lost tissue bulk as well as ensuring a permanent closure and sealing off of the oronasal fistulas. Its reliability can be further increased by avoiding a common complication, namely, flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also, maintaining the patient on Nasogastric feeding for the three weeks postoperative period, until the patient is taken up for surgical separation the pedicle. This helps to ensure a successful and predictable take of the flap at the donor site.

Ballistic trauma

Gunshot injuries are rather serious but uncommon type of trauma in India. Radiologists can contribute substantially in the evaluation and treatment of patients with gunshot wounds. Foreign bodies that enter a patient as a result of trauma are contaminated and produce a range of symptoms. Oral and maxillofacial gunshot injuries are usually fatal due to close proximity with vital structures. Here, we report a case in which radiographic evidence of foreign bodies in the right orofacial region exposed a history of a gunshot injury. The patient did not have any major complaints except for reduced mouth opening. These foreign bodies were clinically silent for approximately 12 years.

Maxillofacial Gunshot Injuries: A Comparison of Civilian and Military Data

To compare military with civilian gunshot wounds (GSWs) in the maxillofacial region in order to establish differences in presentation, morbidity, and surgical management. A cross-sectional study design was used. The University of Florida atJacksonville oral and maxillofacial surgery operating room census and hospital trauma registry were both reviewed to identify maxillofacial GSW cases from 2005 through 2011. Military GSW data (2005 through 2011) were obtained from the US Department of Defense (DOD). The predictor variables were civilian versus military GSW events. The outcome variables of interest included the region of the face involved, race, gender, death during admission, hospital length of stay, and number of days in the intensive care unit (ICU). Descriptive statistics were computed. The sample was divided into military maxillofacial GSWs (n= 412) and civilian maxillofacial GSWs (n= 287 treated of 2,478 presented). A significant difference was measured between study groups regarding the region of the face involved (P= .0451), gender (P ≤ .0001), and race (P ≤ .0001). No significant relationship was measured regarding deaths during admission (P= .6510) for either study group. No standard deviation values for hospital length of stay or number of ICU days were provided by the DOD. The mean hospital length of stay for the military group was within the 95% confidence interval of the civilian group findings (6.0-7.6). The mean number of ICU days for the military group was not within the civilian group's 95% confidence interval (1.9-2.9). These data showed important differences in anatomic location, gender, and race distribution of maxillofacial GSWs between military and civilian populations. Limited analysis of hospital length of stay and number of ICU days might indicate no meaningful difference in hospital length of stay, although there was a statistical difference in the number of ICU days between the 2 populations. Future research comparing surgical strategies in these 2 environments could assist maxillofacial surgeons in providing optimal care to their patients.

Management of Intraoral Gunshot Injury – A Case Report

ABSTRACT Oral and Maxillofacial gunshot injuries are usually lethal due to close proximity with the vital structures. The severity of injury varies according to the caliber of the weapon used and to the distance from which the patient is shot. A case of gunshot injury that was successfully managed by surgical exploration and removal of bullet from left maxillary antrum under local anesthesia is presented. The initial care of facial gunshot wounds strictly adheres to the basics of trauma resuscitation. Early and appropriate surgical management have proved to be influential on the final outcome and aesthetic result. Treatment of gunshot injuries should be planned and carried out carefully. It takes different stages and procedures to achieve the targeted treatment plan. Prevention and control of infection are important in the success of the treatment.

Management of oral & maxillofacial gunshot injuries during the Libyan revolution, case presentations & literature review

Injuries to the head, face, and neck are an important source of mortality and morbidity in combat even though these areas represent only 12% of the body's surface area. The incidence of head and neck injuries in the 21st century has been reported as 20%, 21% and 40%. 16% quoted for most of the conflicts of the 20th century. Data from the Falklands Campaign and Northen Ireland indicate that 3–8% of all casualties sustained middle or lower third fractures of the facial skeleton. Facial lacerations are the most commonly reported maxillofacial injury in war. Specialists who have expertise in maxillofacial surgery therefore remain an indispensable part of casualty care in modern warfare. Terrorist activity appeared to give rise to more head and neck injury than either rural attack or minor or major conventional war, possibly reflecting preference for this target area in an unsuspecting victim. This paper will describe the Libyan experience in treating the maxillofacial injuries in war-time and will present a series of cases that were treated at Aljala Trauma Hospital in Benghazi 2011.

Maxillofacial Gunshot Injuries at an Urban Level I Trauma Center – 10-year Analysis

Optimal management of facial gunshot trauma remains controversial in terms of timing and reconstruction techniques. To analyze current trends in surgical management, a 10-year retrospective study of patients admitted with facial gunshot wounds was undertaken.

Surgical Modalities in Gunshot Wounds of the Face

Maxillofacial traumas caused by gunshot wounds may cause quite varied defects. The objective of this study was to evaluate the reconstruction methods in 12 patients with gunshot wound-related mandibular and maxillofacial bony and soft tissue defects. Twelve patients who were operated on for maxillofacial gunshot wounds at our clinic between 2002 and 2012 were included in the study. Seven patients were wounded in a suicide attempt, and 5 were wounded as a result of an accident or in assaults. Two patients underwent reconstruction using free fibula osteocutaneous flap, 4 patients received the free radial forearm osteocutaneous flap, 2 patients received costal bone graft, and 3 patients received iliac bone grafts. Satisfactory functional and aesthetic outcomes were achieved in cases where staged secondary reconstruction, balloon treatment, and consecutive fat and steroid injections into the depressed scar areas were applied. In conclusion, the basic goal in maxillofacial reconstruction is the functional and aesthetic reconstruction of the contours. Because it is not easy to get perfect results with only 1 clinical approach or 1 method, the proper timing and reconstruction method should be selected.

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early, although, surprisingly, it is not always necessary. Haemodynamic resuscitation, followed by thorough patient evaluation, is done to rule out concomitant injuries often associated with warfare injuries. They may go unnoticed when attention is directed primarily to an extensive facial injury 4–7 . After early resuscitation, careful history and physical examination and paraclinical diagnostics are necessary for correct management. Craniofacial computed tomography-scans with soft tissue and bone imaging in different views (axial, coronal and three dimensional) are the procedures of choice for diagnosis of facial injuries. Consultation with different specialists is often necessary for treatment. Surgical management of facial gunshot wounds is basically divided into three stages: (1) debridement, fracture stabilisation, and primary closure; (2) reconstruction of hard tissues, provided soft tissue coverage is adequate; and (3) rehabilitation of the oral vestibule, alveolar ridge, and secondary correction of residual deformities and dental implants 6,8 . Herein, we review and evaluate the current trends in the management of maxillofacial gunshot injuries. Discussion The authors have referenced some of their own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies. Debridement

Establishment of a three-dimensional finite element model for gunshot wounds to the human mandible

ObjectiveTo investigate the feasibility of a finite element model as an ideal research tool for human maxillofacial gunshot wounds. MethodsMandible CT scan data on the Chinese Visible Human were imported into MIMICS software to obtain the surface mesh of the mandible. Then, these surface-meshed models were imported into ANSA software for automatic net generation. Elements and nodes were partitioned on the basis of the mesh to obtain a three-dimensional finite element model for the mandible with every internal parameter consistent with those of our previously developed model in the pig mandible. The finite element model was imported into LS-DYNA for computation. Finally, the LS-POST was used to complete the simulation and the measurements. ResultsA three-dimensional finite element model was successfully established for gunshot wounds in the human mandible. The stress distribution and the degree of injury were simulated dynamically for shots from two types of projectiles in the mandible at one entry angle and at three impact velocities. ConclusionThree-dimensional finite element models will become ideal research tools for treatment of ballistic wounds of the human maxillofacial region. Using this human mandibular model as a foundation, we will be able to successfully develop three-dimensional finite element models for human maxillofacial gunshot wounds.

Dynamic simulation and preliminary finite element analysis of gunshot wounds to the human mandible

ObjectiveDue to the complications arising from gunshot wounds to the maxillofacial region, traditional models of gunshot wounds cannot meet our research needs. In this study, we established a finite element model and conducted preliminary simulation and analysis to determine the injury mechanism and degree of damage for gunshot wounds to the human mandible. MethodsBased on a previously developed modelling method that used animal experiments and internal parameters, digital computed tomography data for the human mandible were used to establish a three-dimensional finite element model of the human mandible. The mechanism by which a gunshot injures the mandible was dynamically simulated under different shot conditions. First, the residual velocities of the shootings using different projectiles at varying entry angles and impact velocities were calculated. Second, the energy losses of the projectiles and the rates of energy loss after exiting the mandible were calculated. Finally, the data were compared and analysed. ResultsThe dynamic processes involved in gunshot wounds to the human mandible were successfully simulated using two projectiles, three impact velocities, and three entry angles. The stress distributions in different parts of mandible after injury were also simulated. Based on the computation and analysis of the modelling data, we found that the injury severity of the mandible and the injury efficiency of the projectiles differ under different injury conditions. ConclusionsThe finite element model has many advantages for the analysis of ballistic wounds, and is expected to become an improved model for studying maxillofacial gunshot wounds.

Changing Pattern of Pediatric Maxillofacial Injuries at the Accident and Emergency Department of the University Teaching Hospital, Ibadan–A Four-Year Experience

Maxillofacial injuries are common among polytraumatized patients, and in Nigeria, the incidence seems to be on the increase. This probably is related to the drive of industrialization and the increase in the number of road traffic accidents. Delays in attending to severe maxillofacial injuries can be grave because of concomitant injuries that can be life threatening. This is a prospective review of maxillofacial injuries in patients less than or equal to 16 years of age who were seen at the Accident and Emergency Department between October 2002 and December 2006. In all the patients, the accident and emergency physicians carried out initial resuscitation, and thereafter, they were referred to the maxillofacial unit on call. A total of 611 patients with maxillofacial injuries were seen during the study period and of this, 134 (22%) were less than or equal to 16 years old. The male:female ratio was 1.1:1.0. Road traffic accident (RTA) was the most common etiological factor in 73 (54.5%) cases, while gunshot injuries accounted for 6 (4.4%) cases. Soft tissue lacerations were the most common maxillofacial injuries occurring in 90 (55.9%) cases; mandibular fractures were the most common bony injury in 17 (13.4%). The upsurge in maxillofacial gunshot injuries in the pediatric age group is alarming and this may be a reflection of the global changes (westernization and drug-related offenses like armed robberies) and the harsh economic conditions in this community.

Psychiatric Analysis of Suicide Attempt Subjects Due to Maxillofacial Gunshot

The studies of maxillofacial gunshot injuries mainly focused on evaluating the surgical interventions and physical outcomes of the procedures. In this study we aimed to analyze the pre- and post-injury psychiatric status of the patients with self-inflicted gunshot wounds to the face. This study is based on 12 subjects who attempted suicide resulting in extensive maxillofacial injuries using guns placed beneath their chins. The psychiatric evaluation was conducted by interview and using SCID-I, SCID-II, MMPI, Rosenberg Self-Esteem Scale and Suicide Probability Scale. Two subjects were healthy, 1 had bereavement, 6 had current and 5 had previous MDD (major depressive disorder), 2 had dysthymic disorder, 3 had alcohol abuse, 2 had drug abuse and 4 had antisocial personality disorder. The suicidal group was more socially introverted according to MMPI. According to Rosenberg self-esteem subscale, self esteem, the constancy of self respect and depressive mood subtests were statistically significant in the suicide group compared to the healthy controls (P < 0.01). Depressive spectrum disorders are the most common causes. It is obvious that untreated or undiagnosed depression may increase risk of committing suicide. The changes in the physical facial appearance after the suicide attempt caused impairment of self-esteem and the constancy of self-respect. Similar to other studies, none of our patients reattempted suicide and all tried to return to their pre-injury lifestyle and appeared to accommodate to the stigma of their physical deformities. Early diagnosis and treatment should be considered as a factor to reduce the risk for suicide attempt.

Elevated blood lead resulting from maxillofacial gunshot injuries with lead ingestion

Purpose: The purpose of this study was to identify the contribution of ingested lead particles to elevated blood lead concentrations in victims of gunshot injury to the maxillofacial region. Patients and Methods: As part of a larger study of the effects of retained lead bullets on blood lead, a retrospective review of study findings was completed on 5 of 8 patients who sustained injuries to the maxillofacial region. These 5 patients were recruited into the larger study within 11 days of injury and showed a penetration path for the projectile that engaged the upper aerodigestive tract. All subjects were recruited from patients presenting for care of their gunshot injuries to a large inner-city trauma center with a retained bullet resulting from a gunshot injury. An initial blood lead level was measured for all recruited patients and repeated 1 to 17 weeks later. Medical history was taken along with a screening and risk factor questionnaire to determine other potential or actual sources (occupational/recreational) of lead exposure. 109Cd K-shell x-ray fluorescence determinations of bone lead were completed to determine past lead exposure not revealed by medical history and risk factor questionnaire. Radiographs taken of the abdomen and chest, required as a part of the patient's hospital care, were retrospectively reviewed for signs of metallic fragments along the aerodigestive tract. Results: All 5 patients retained multiple lead pellets or fragments at the site of injury, sustained fractures of the facial bones, and showed increases in blood lead. Three of the 5 study subjects who sustained maxillofacial gunshot injuries involving the mouth, nose, or throat region showed metallic densities along the gastrointestinal tract indicative of ingested bullet fragments. Each patient with ingested bullet fragments showed rapid elevation of blood lead exceeding 25 μg/dL and sustained increases well beyond the time when all ingested fragments were eliminated. A 3-year follow-up on these 3 patients showed significantly sustained elevation of blood lead but less than that observed during the initial 6 months after injury. None of the 5 study subjects showed any evidence of metallic foreign bodies within the tracheobronchial regions indicative of aspiration. Conclusion: Ingestion of lead fragments can result from gunshot injuries to the maxillofacial region and may substantially contribute to a rapid increase in blood lead level. Prompt diagnosis and elimination of ingested lead fragments are essential steps necessary to prevent lead being absorbed from the gastrointestinal tract. Increased blood lead in victims after gunshot injuries must be fully evaluated for all potential sources, including recent environmental exposure, absorption of lead from any remaining bullets in body tissues, and the possibility of mobilization of lead from long-term body stores such as bone. © 2003 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofacial Surg 61:593-603, 2003

Biomechanical changes in the head associated with penetrating injuries of the maxilla and mandible: An experimental investigation

Purpose: In this experiment, we studied the craniocerebral injury that occurs due to the transmission of forces when maxillofacial gunshot wounds are sustained by the facial bones and cranium. Materials and Methods: Forty fresh pigs' heads were wounded by one of the following methods: steel spheres weighing 1.03 g at an impact velocity of 1,400 m/s, steel spheres weighing 1.03 g at an impact velocity of 800 m/s, M193 military bullets, or M56 military bullets. Pressure waves in the brain, acceleration of the head, and stress changes in the facial bones and cranium at the moment of the impact were recorded by pressure and acceleration transducers and strain gauges and were statistically compared. Results: Some obvious differences between the mechanical values obtained from high-and low-velocity missile wounds were found. A negative relationship between the peak value of the pressure wave in the brain and the distance from the point of impact to the transducer was obtained. The acceleration of the head in the direction of the ballistic path was the strongest in absolute value. There were differences in the stress values between the mandible and the temporal bone. Conclusions: Acceleration of the head, pressure wave changes in the brain, and injury from bony stress conduction all play important roles in associated craniocerebral damage after maxillofacial firearm wounds. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:552-556, 2002

Discussion

The management of maxillofacial gunshot wounds is a familiar experience at every level I trauma center in a major metropolitan area, but such injuries can also occur in more remote settings. This article focuses on the management of 121 gunshot patients over a 4-year period. The type of injuries, their mortality, and management is similar to that at our center. Our experience has been that surgical intervention is more frequently than not required to address both the skeletal and soft tissue injuries. Early management soon after the patient has been stabilized from other associated life-threatening concerns is the best way of addressing the maxillofacial trauma. Application of the principles of stabilization of the skeletal components with some type of rigid internal fixation or external fixator is indicated to obtain the very best skeletal reconstruction. Bone grafting to replace absent or severely damaged skeletal parts, where indicated, should also be considered in the reconstruction. Avulsed hard and soft tissues must be replaced, and microvascular composite grafts are frequently needed because of the severe tissue loss. Primary closures that are done under tension will usually fail, as the blast effect of the injury cannot be determined early. The damaged soft tissues, with compromised blood supply, will frequently necrose in the first 5 to 7 days. It is actually better in many cases to delay some soft tissue treatment until demarcation has taken place and debridement can be completed to well-vascularized margins. Then, definitive soft tissue management can occur.