Skip to main content

Advertisement

SpringerLink
Log in

Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios

  • Comparative Study
  • Published:
Journal of Maxillofacial and Oral Surgery Aims and scope Submit manuscript

Abstract

Introduction

The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure.

Aim

The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts.

Methods

This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3 years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery.

Results

Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes.

Conclusion

In today’s low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Saraswat V (2009) Injury patterns in low intensity conflict. Indian J Anesth 53:672–677

    CAS  Google Scholar 

  2. Chen AY, Stewart MG, Raup G (1996) Penetrating injuries to the face. Otolaryngol Head Neck Surg 115:464–470

    CAS  PubMed  Google Scholar 

  3. Kaufman Y, Cole P, Hollier LH (2009) Facial gunshot wounds: trends in management. Craniomaxillofac Trauma Reconstr 2:85–90

    Article  Google Scholar 

  4. Anmole O, Osunde O, Akhiwu B (2017) A 14-year review of Craniomaxillofacial Gunshot wounds in a resource-limited setting. Craniomaxillofac Trauma Reconstr 10:130–137

    Article  Google Scholar 

  5. Gruss JS, Antonyshyn O, Phillips JH (1991) Early definitive bone and soft tissue reconstruction of major gunshot wounds of the face. Plast Reconstr Surg 87:436–450

    Article  CAS  Google Scholar 

  6. Kihtir T, Ivatury RR, Simon RJ et al (1993) Early management of civilian gunshot wounds to the face. J Trauma 35:569–577

    Article  CAS  Google Scholar 

  7. Dolin J, Scalea T, Mannor L et al (1992) The management of gunshot wounds to the face. J Trauma 33:508–514

    Article  CAS  Google Scholar 

  8. Gruss JS, Mackinnon SE, Kassell EE, Copper PW (1985) The role of primary bone grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg 15:17–24

    Article  Google Scholar 

  9. Cole RD, Browne JD, Phipps CD (1994) Gunshot wounds to the mandible and midface: evaluation, treatment, and avoidance of complications. Otolaryngol Head Neck Surg 111:739–745

    Article  CAS  Google Scholar 

  10. Stuehmer C, Blums KS (2009) Influence of different types of guns, projectiles and propellants on patterns of injury to the viscerocranium. J Oral Maxillofac Surg 67:775–781

    Article  Google Scholar 

  11. Motamedi MH (2003) Primary management of maxillofacial hard and soft tissue gunshot and shrapnel injuries. J Oral Maxillofac Surg 61:1390–1398

    Article  Google Scholar 

  12. Clark N, Birely B, Manson PN, Slezak S (1996) High energy ballistic and avulsive facial injuries: classification, patterns and an algorithm for primary reconstruction. Plast Reconstr Surg 98:583–601

    Article  CAS  Google Scholar 

  13. Dufresne CR (1992) The use of immediate grafting in facial fracture management: indications and clinical considerations. Clin Plast Surg 19:207–217

    CAS  PubMed  Google Scholar 

  14. Thoresby FP, Darlow HM (1967) The mechanisms of primary infection of bullet wounds. Br J Surg 54:359–361

    Article  CAS  Google Scholar 

  15. Dean NR, Mc Kinney SM (2011) Free flap reconstruction of self-inflicted gunshot wounds. Craniomaxillofac Trauma Reconstr 4:25–34

    Article  CAS  Google Scholar 

  16. Deveci M, Sengenzer M, Selmanpakoglu M (1998) Reconstruction of gunshot wounds of the face. Gazi Med J 9:47–56

    Google Scholar 

  17. Kazanjian VH, Converse JM (1949) Gunshot wounds. In: The surgical treatment of facial injuries. Williams and Wilkins, Baltimore, p 78

  18. Siberchicot F, Pinsolle J, Majoufre C et al (1998) Gunshot injuries of the face. Analysis of 165 cases and reevaluation of the primary treatment. Ann Chir Plast Esthet 43:132–140

    CAS  PubMed  Google Scholar 

  19. Vayvada H, Menderes A (2005) Management of close range, high energy shotgun and rifle wounds to the face. J Craniofac Surg 16:794–804

    Article  Google Scholar 

  20. Furan ND, Farwell DG, Smith RB (2005) Definitive management of severe facial trauma utilizing free tissue transfer. Otololaryngol Head Neck Surg 132:75–85

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Command Military Dental Centre (Northern Command), Udhampur, Jammu & Kashmir, India

    Priya Jeyaraj

  2. Dental Centre, INHS Kalyani, Vishakhapatnam, Andhrapradesh, India

    Ashish Chakranarayan

Authors
  1. Priya Jeyaraj
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ashish Chakranarayan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Priya Jeyaraj.

Ethics declarations

Conflict of interest

The author of this article has not received any research grant, remuneration, or speaker honorarium from any company or committee whatsoever, and neither owns any stock in any company. The author declares that she does not have any conflict of interest.

Research Involving Human Participants and/or Animals

All procedures performed on the patients (human participants) involved were in accordance with the ethical standards of the institution and/or national research committee, as well as with the 1964 Declaration of Helsinki and its later amendments and comparable ethical standards.

Ethical Approval

This article does not contain any new studies with human participants or animals performed by the author.

Informed Consent

Informed consent was obtained from all the individual participants in this study.

Statistical Analysis of Esthetic and Functional Outcomes Between Groups 1 and 2

Statistical Analysis of Esthetic and Functional Outcomes Between Groups 1 and 2

Statistical Package for the Social Sciences (SPSS) 16.00 for Windows was used to statistically analyze and compare the results between the two Groups. At 95% class interval, following were the observations (the bar on the right in each graph representing the respective Group): (Table 2 and Figs. 8, 9, 10, 11, 12, 13, 14 and 15).

Table 2 Graphic comparison of evaluated parameters between Groups 1 and 2
Full size table
Fig. 8
figure 8

Statistical comparison of residual cosmetic deformity between Groups 1 and 2

Full size image
Fig. 9
figure 9

Statistical comparison of requirement for re-surgery between Groups 1 and 2

Full size image
Fig. 10
figure 10

Statistical comparison of chronic/recurrent infection at operated site between Groups 1 and 2

Full size image
Fig. 11
figure 11

Statistical comparison of neurological deficits between Groups 1 and 2

Full size image
Fig. 12
figure 12

Statistical comparison of reduced masticatory efficiency between Groups 1 and 2

Full size image
Fig. 13
figure 13

Statistical comparison of occlusal discrepancy between Groups 1 and 2

Full size image
Fig. 14
figure 14

Statistical comparison of impaired speech between Groups 1 and 2

Full size image
Fig. 15
figure 15

Statistical comparison of restricted mouth opening between Groups 1 and 2

Full size image

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jeyaraj, P., Chakranarayan, A. Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios. J. Maxillofac. Oral Surg. 17, 466–481 (2018). https://doi.org/10.1007/s12663-018-1089-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12663-018-1089-0

Keywords

Search

Navigation