in maxillofacial region

1. SEMINAR ON GUNSHOTWOUNDS
Present by
Cathrine Diana PG II

2. • CONTENTS
• Introduction
• Demographic
• Characteristics of missile injuries
• classification of fire arm injury
•
• Management
– Primary management
– Intermediate
– Definitive management
• Residual problems and their management
• Summary

3. A case report

4. Introduction
• Ballistic trauma or gunshot wound (GSW) is a form of physical
trauma sustained from the discharge of arm
• firearms used in armed conflicts, civilian sporting, recreational
pursuits and criminal activity. Ballistic trauma is sometimes
fatal for the recipient, or causes long term consequences.
• GSWs are the second most source of injury and death , after
motor vehicle accidents

5. Demographics
• The majority of civilian firearm injuries are sustained from
handguns (86%),
• shotguns (8%) and
• rifles (5%).
• 36% 0f patients die following admission.
• All of the deaths were secondary to injuries to the chest, abdomen
or brain.
• There is small percentage of deaths associated with isolated facial
injuries
• International Journal of Medical Toxicology and Forensic Medicine
. 2013

6. • National firearm murder rate of 0.36 per 100,000 people
Equivalent to roughly one tenth of the rate of firearm murders
in the United States. 92% were victims of homicidal attacks, 2
% suicidal and 2% accidental
• Abdomen (39%) and head (30.30%) were the two most
common entry sites for the bullets
International Journal of Medical Toxicology and Forensic Medicine
. 2013

7. Ballistics
the science of projectile motion, to understand the injuries caused by
various firearms.
 The potential problems of a wound caused by a projectile can be
better anticipated if one has some knowledge of the weapon and
projectile type that cause the wound.
 Ballistic science typically divided into three stages :
o Internal ballistics
o External ballistics
o Terminal ballistics
Atlas Oral Maxillofacial Surg Clin N Am 21 (2013) 15e24

8. Internal ballistics
• Forces that apply to a projectile from the time the propellant
is ignited to the time the projectile leaves the barrel.
• An important consideration is barrel length. In general, longer
barrels (rifles) allow the force of the propellant to act on the
projectile longer and generate higher velocities and stabilizes
the bullet over longer distance.

9. • Most handguns and rifles have barrels
with internal grooves referred to as
rifling , This keeps the projectile stable
in flight over longer distances
• External ballistics: forces that act on
the bullet in flight, primarily the weight
and shape of the bullet

10. Terminal ballistics: study of bullet behavior once it impacts the
target – how much energy is transferred and the resultant
damage: most import for the surgeons.

11. Factors affects the degree of injury
Factors
affect the
degree of
injury
Velocity and
Mass of the
bullet
Composition
and shape of
the bullet
Extent of
deviation of
the bullet
extend of
cavitation
drag and
retardation

12. Velocity and mass of the bullet
 kinetic energy has been used as the basis to explain wounds caused by the
gunshot
KE = mv2
where KE is kinetic energy , ( m ) is the mass of the projectile, and ( v ) is the
velocity of the projectile .
 Wounding power is typically related to the amount of kinetic energy
transferred to the target: P = m(V impact – V exit)2 where P is power, m is
mass of the projectile,and V is velocity
 Based on these formulas, the velocity of a projectile considered more
important than its mass in wounding power .
 Considering a typically sized projectile velocity of approximately 50 m/s
is required to penetrate the skin, and a velocity of around 65 m/s will
fracture the bone .

13. Composition and shape of the bullet
• Earliest projectile was a stone or lead ball Over time
theprojectile evolved to the conical-shape .
• Full-metal jacket with exposed lead tips to expand on impact
for maximum tissue destruction

14. Extent of deviation of the bullet
 all projectiles become unstable in flight
because of the center of gravity lies
behind the center of resistance of the
bullet (bullet tip
 yaw ; Oscillation of the bullet around
there long axis
 tumble ; rotation of the bullet around
there center .
 tumbling lead to Increase in their
profiles causes more tissue wounding
because it presents a larger surface
areaIncreased probability of
fragmentation

15. COMPONENTS OF PROJECTILE
WOUNDING
 Penetration : a bullet must
penetrate to a sufficient depth
to cause damage.
 Permanent cavity : the space
that results from direct tissue
disruption and destruction.
 Fragmentation : missile
fragment or secondary
fragments such as clothing or
bone.

16. • Temporary cavity : consists of a “shock-wave” like effect. It
has two main effect-1-rush air and contaminate into cavity .2-
pressure effect means damage well beyond track of missile.
• Temporary cavitation can be up to 6-10 times the diameter of
a medium to high velocity bullet.
• results in stretching Of elastic tissues .
 most tissues has an elastic nature and ability to recover from
stretching except some tissues such as brain ,liver,spleen


17. Stress wave :
 Precedes the cavitation phenomena
 Not like the shock wave it does not have the characteristic or
velocity of the shock wave produced by an explosion
 Transmitted through fluid filled structures like blood vessels
causing endothelial damage and thrombosis
 Fracture of bone away from the wound tract is due to stress
wave rather than cavitation
 For maxillofacial region : the stress wave is more important
than cavitation .

18. CLASSIFICATION OF FIRE ARM INJURY
low velocity
• ( < 350 m/s )
Intermediate velocity
• (350–600 m/s)
high velocity
• (> 600 m/s)

19. • Short gun injuries: (<1000ft/s)
• These injuries have to be classified separately due to the
particular design of a cartridge- firing sporting gun ,based on
the range
• Type I < 5 m
• Type II injuries (5–12 m
• Type III injuries > 12 m

20. • Type I < 5 m ;
• the pellets strike the target as a single mass,
• resulting in massive kinetic energy transfer and tissue avulsion
• high mortality rate (85–90%)
• Type II injuries (5–12 m) ;
• usually result in much less tissue destruction.
• there is significant dispersal of the pellets and loss of energy.
• Penetration may occur through deep fascia, but fractures are rare.
Ocular injuries can occur as well as embolization of lead pellets,
• mortality rate (15–20%)
• Type III injuries > 12 m ;
• usually only the skin is penetrated
• mortality is rare (0–5%)

21. Based on pattern of injury
• Nonpenetrating : grazing or
blast wound
• Penetrating : low impact
velocity ,bullet does not exit
• Perforating : high velocity ,
bullet in and out
• Avulsive : massive wounds
with avulsion and loss of
tissues .

22. • Entrance holes usually have an
abrasion collar or contusion
ring around them. The ring is
an area of epidermis free
margin around the entrance of
the gunshot and is caused as
the bullet penetrates the skin it
mechanically indents and
abrades or scrapes the
epidermis of the skin leaving
the collar or ring.

23. Direction of trajectory
• Tangential
• Transverse
1. High level
2. Mid –level
3. Low level
4. Neck

24. Site of wound
• UPPER FACE
• MIDDLE FACE
• LOWER FACE
• NECK

25. Gustillo-Anderson classification
Gustilo Type I II IIIA IIIB IIIC
Energy Low energy Moderate High High High
Wound Size < 1 cm > 1cm >10cm >10cm >10cm
Soft Tissue Minimal Moderate Extensive Extensive Extensive
Contamination Clean
Moderate
contamination
Extensive Extensive Extensive
Fracture Pattern
Simple fx pattern
with minimal
comminution
Moderate
comminution
Severe
comminution or
segmental
fractures
Severe
comminution or
segmental
fractures
Severe
comminution or
segmental
fractures
Periosteal
Stripping
No No Yes Yes Yes
Skin Coverage Local coverage Local coverage
Local coverage
including
Requires free
tissue flap or
rotational flap
coverage
Typically requires
flap coverage
Neurovascular
Injury
Normal Normal Normal Normal
Exposed fracture
with arterial
damage that
requires repair

26. Contamination
 The projectiles from firearms are not sterile , The heat generated by
the discharge of the propellant as well as the friction between the
bullet and barrel is not sufficient to sterilize the bullet.
 Contamination can occur from the bullet and also from skin flora
and foreign bodies (clothing) carried into the wound ,and wounds in
which the bullet traverses the aerodigestive tract or paranasal
sinuses are at particular risk .
 Prophylactic coverage with broad-spectrum antibiotics, typically a
second-generation cephalosporin, and tetanus prophylaxis,should
be initiated in all gunshot wounds.
 Lead toxicity may occur but it is a rare complication

27. • Duration
– initiate as soon as possible
• studies show increased infection rate when antibiotics
are delayed for more than 3 hours from time of injury
– continue for initial 72 hours after drainage
– 48 hours after each procedure
• Tetanus booster if not up to date

28. Management
• The chief objective in a missile injury is preservation of life
• It has been estimated that for every 10 minutes of delay in
definitive treatment, survival drops by 10%.
• Gunshot wounds to the head are the most lethal of all firearm
injuries.3 it is estimated they have a fatality rate greater than
90%. Those to the myocardium have fatality rates reaching
80%. Intra-abdominal injuries from gunshot wounds tend to
involve the small bowel (50%), colon (40%), liver (30%) and
abdominal vascular structures (25%).

29. • Primary management to be consider under the following
headings:
• Prevention of respiratory obstruction
• Management of blood loss and treatment of shock
• Prevention of infection
• Control of pain and discomfort

30. Management of gun shot wounds:
Late phase
soft tissue and bone reconstruction
Intermediate phase
Diet and feeding Oral hygiene Control of infection
Immediate management
primary survey
(A,B,C,D,E )
Secondary survey primary surgery

31. • 3 PEAKS OF DEATH
• There are 3 peaks of death when it comes to deaths following
trauma.
• 1st PEAK: occurs at the scene of injury, usually due to severe
head or spinal cord injury or massive blood vessel injury, like
gun shot wound to the chest striking the heart or major
vessel.
• 2nd PEAK: occurs within 6 hours of injury and stems from
internal bleeding and brain swelling.
• 3rd PEAK: it is a few weeks after injury and occurs in the
Intensive Care Unit from infection and multi system organ
failure.

32. Airway
• compromised by hemorrhage, swelling, or in low GCS – fall
back of tongue
• Extensive gunshot injury to the middle base of tongue-
Prolapse of tongue back against post. Wall of pharynx
• Foreign body obstruction from fragments of bone, teeth,
denture
• Edema of tongue base, oropharynx and larynx
• Laceration of soft palate or other parts of mouth causing
mechanical obstruction of airway

33. Immediate management of gunshot
wounds
• Immediate management includes:
• Posture: semi-prone or face down position is what should
be used.
• Toilet of airway: removal of all foreign bodies by fingers or
suction
• Control of haemorrhage – by pressure pack, anterior and
posterior nasal packing
• Tongue traction: via transverse sutures through posterior
part of the tongue
• Endotracheal intubation
• Upper airway by-pass – cricothyroidotomy, later
tracheostomy

34. • Indication of tracheostomy in
GSW:
• Obstruction due to upper airway
edema
• When prolonged ventilation is
needed
• To facilitate anesthesia – in
certain surgical repair
• To ensure a safe post operative
recovery

35. Control of hemorrhage
• Direct pressure
• Direct clamping or ligation through the wound.
• Anterior and posterior nasal packs for midface gunshot
wounds
• Angiography and embolization for uncontrolled larger bleeds
and expanding hematoma
• Low ECA ligation – necessary only when there is need to
remove a foreign body which has perforated it at some distant
level. Surgical ligation of the external carotid artery is often
ineffective for bleeding control due to its robust collateral
vessels

36. Circulation and shock
• assess the pulse at the wrist, neck, or groin and measure the
blood pressure. (systolic BP <90)
• The degree of shock directly related to the reduction in the
volume of the circulating blood. The clinical evidence of
shock was apparent only if 30% loss occurred. Death can
occur when > 40% of blood loss occurs and the volume is not
replaced

37. • Two clinical pictures may be seen after injury:
• Neurogenic shock: brought out by severe pain and mental
stress, may occur without much blood loss. Sweating, pallor,
moderate fall in BP and bradycardia , slow threading pulse are
common signs.
• Oligaemic shock: caused by rapid reduction of in circulating
blood volume from external or internal hemorrhage. Pallor of
face and lips, cold extremities, hypotension and fast thready
pulse, Decreasing alertness, Nausea/vomiting are the signs.

38. Fluid replacement
• Gray and coopel(1975) recommended hartmann’s solution
for early management of missile causalities. Upto 2 ltrs can
be given, if there is no response to initial transfusion, O Rh
negative blood can be given.
• Monitoring assisted by urine output, CVP (1.25kPa) blood
pressure.
• The largest amount of replacement is needed when there is
greatest degree of muscle destruction

39. Secondary survey
• EXPOSE, EXPLORE AND EVALUATE
• Inspection - contusion, abrasion, laceration, swelling, nerve
fallout, bruising and bleeding. Approximately 17% of patients
with a GSW to the face have associated brain injuries, and 8%
have associated C-spine injuries.
• Eye injuries are present in approximately 13%.
• complete ocular examination should consist of an evaluation
of general acuity, light perception, ocular motility, pupillary
reactivity, examination of the conjunctiva and eyelids

40. • palpation- for bone discontinuity, surgical empysema, tmj
movements, any foreign body, broken prostheses,laceration
hematoma avulsed, missing and fractured teeth, dental
occlusion

41. Imaging
• spiral Computed tomography (CT) is the gold standard
• 1mm axial views, from the top of the cranium through the
bottom of the mandible, should be obtained.
• Both coronal and sagittal views are necessary.
• 3 D reconstruction – complex fracture
• 100% sensitive and specific for facial bone injury

42. • CT does not give sufficient detail of dental structures, root
damage, or tooth position, which require panoramic
radiographs for appropriate assessment.
• C- spine and chest X-rays should be obtained to visualise
bullet fragments.

43. Prevention and control of infection
• Preventive measures: high velocity projectile causes risk of gas
gangrene. A prophylactic dose of polyvalent antitoxin is to be
given Appropriate antibiotic (crystalline penicillin – 2,000,000 U
+ streptomycin) and tetanus toxoid booster dose is also given.
Gentamycin (1.2mg/kg) may be added for gram negative
spectrum. In case of meningeal perforation, intramuscular
sulpha-diazine or sulphadimidine or chloramphenicol should be
administered.
• Control of infection: local toilet of wounds, care of airway to
prevent septicaemia and pulmonary infection. The antibiotics
need to be continued for 3-4 weeks.
•

44. Based on Gustillo-Anderson classification
 1st generation cephalosporin for 24 hours
after closure
 1st generation cephalosporin for gram positive
coverage.
 Aminoglycoside (such as gentamicin) for gram
negative coverage in type III injuries
o the cephalosporin/aminoglycoside should
be continued for 24-72 hours after the last
debridement procedure
penicillin should be added if concern for anaerobic
organism
 Flouroquinolones
o should be used for fresh water wounds or salt water wounds
o can be used if allergic to cephalosporins or clindamycin
 Doxycycline and ceftazidime
o can be used for salt water wounds

45. Control of pain and discomfort
• More than pain, there is considerable discomfort from
maxillofacial injuries.
• Avoid giving powerful analgesics, which depress the level of
consciousness and respiration.
• However it is important to keep to minimize discomfort early
by local toilet, support of mobile mandibular fractures,
posture, suction and administration of IV fluids

46. Documentation and record keeping
• Date and time of injury
• Cause of injury: records are frequently sketchy. Wounding
agent must be recorded to know the range and its ballistics.
• Treatment given: fluids given, antisera transfused, drugs
administered.
• Description of injury: best recorded by simple line diagrams
for soft-tissue lacerations, tissue loss, and entry and exit
points. The method of temporary or permanent fixation can
also be displayed.

47. Definitive management of wounds
• After initial management, the treatment falls into 2 phases
• Primary treatment - aimed to achieve healed tissue with
minimum deformity
• Reconstructive treatment of residual bone and soft tissue

48. Primary treatment:
Soft tissue
• It is advised to go for much definitive reconstruction as
possible at the time of original surgery
• 1-primary suture= facial missile wound seen with in 24 hrs.
• 2-wound seen later then this and short range short gun
blast=packing open , when clean , delayed primary closure
and drained
• 3-wound edge should be excised by 1-2mm to create non
bevelled edge on an even subcutaneous bed, which can be
mobilized by undermining for proper approximation, but
should not exceed beyond 5cm.

49. • 4-watertight closer indicated after debridement and fixation
of fractures
• 5- reconstruction of lip sphincter is prime important
• Area of skin lost , should be left to promote epithelisation or
covered with split skin graft.
• In high velocity injury Serial surgical debridement” second-
look procedures”, at 24-to 48 hours intervals which reopen
the soft tissue to define additional areas of soft tissue
necrosis, drain hematoma or developing fluid collections,
and ensure bone integrity.

50.  All shotgun wounds of the mandible should be drained and it
is better to be placed in several places
 Where ever possible , placed away from suture lines
 In contaminated comminuted fracture the drain better be
(through –and through ) to facilitate irrigation
 Removal of the drain depend on the amount of discharge on
the dressing which should be changed at least once daily
 In general drain should be removed after progressive
shortening within the first 10 postoperative days .

51. hard tissue
• Difference from civilian
• Mandibular:
• mainly comminuted,compound,contaminated
with soft tissue loss.
• Viability of bony fragments and Extend of injury
cannot be accurately evaluated.
• Maxillary
• rarely produce classical Lefort pattern
• More tissue avulsion so more oro antral and oro
nasal communication.
• Alveolar fractures
• More injury to ear ,eye ,nose, parotid gland
,facial nerve and lacrimal apparatus
• Communion of ramus and ZMC fracures leads
to serious complications

52. • The goal is correct reduction and stabilisation of facial bone
fractures and minimal morbidity for patients
• Closed reduction (MMF)
• External pin fixation
• ORIF-necessary for optimal results.
• But in most of the studies, infection rates are found to be
higher in ORIF cases as compared to MMF. Also, MMF is to be
done for some time in all cases with ORIF for precise occlusal
correction.
• But according to Majeed etal Injury, (Int. J. Care Injured 45
(2014) 206–211) Patients treated by open reduction tended to
have less complications as compared to closed reduction for
management of comminuted but continuous mandible defects
after gunshot injuries

53. • Reconstruction plates: the shattered and scattered bone can
be found and secured to a reconstruction plate to obtain
mandible continuity
• Oro- anral or oro- nasal fistula has to dealt during
reconstructive phase of treatment.
• When maxillary antrum is penetrated or perforated , it should
be packed with medicated gauze pack
• Recent studies suggest reconstruction of bony defects in upper
and middle part of face, provided less contamination and
adequate soft tissue coverage

54. Dural tears and brain damage
• The management is within the scope of neurosurgery, but its
recognition is a responsibility of the maxillofacial surgeon.
• CSF leak may be difficult to recognize in case of severe bone
and soft tissue injury. The presence of displaced bone visible in
radiographs in areas like posterior wall of frontal sinus,
ethmoidal sinus, cribriform plate or orbital roof and evidence
of air within cranial cavity are diagnostic. Early reduction of
fractures at this stage even without dural repair will reduce
the risk of meningitis.
• less severely injured patients should be operated on within 3
to 8 hours

55. Foreign bodies in tissues
• A bullet its fragment may be buried deep
into the oro-facial region and may lead
to formation of abscess or aneurysm.
Their removal is not easy. Several
radiographs taken at right angles to each
other are required to identify the exact
position. The finger is the most sensitive
probe that will palpate the buried object.
If a curved hemostat is passed along the
line of the finger, the foreign body can be
grasped and removed through a
relatively small surgical wound by
experienced surgeon

56. Ear and eye
• hearing loss is a complication of gunshot wound even when
the ear is not directly involved. Pressure wave and cavitation
during passage of missile may cause cochlear and middle ear
damage. Injury to orbit may result. Patient needs specialists of
the respective fields to manage these injuries

57. • PENETRATING INJURIES OF NECK: Gunshot wounds involving the
face may be associated with an entrance or exit wound in the neck,
which is divided into three zones originally described by Monson and
colleagues from Cook County Hospital.
• ZONE 1: area from clavicles to cricoid cartilage. Injury to this zone
has high mortality rate (12%) due to haemorrhage., vessel occlusion
by external hematoma, later complication as thrombosis formation ,
clot/emboli propogation – interruption in cerebral blood flow and
consequence brain damage
• The onset of stridor is the indication for immediate exploration

58. • ZONE 2: area from cricoid
cartilage to angle of mandible It
is the largest area, hence most
commonly involved. Surgical
exploration is warranted in case
of penetrating injury.
• ZONE 3: from angle of mandible
to the skull base.
• Perforation of the pharynx or
upper part of oesophagus may
lead to retropharyngeal abscess
formation

59. Penetrating injury to the neck that need urgent
management
expanding
hematoma
neurologic deficit
Signs of
tracheal injury
hoarseness
stridors
subcutaneous
emphysema
dysphonia, or
hemoptysis
signs of vascular
injury

60. • Vascular injuries were found in 48%,
• spinal cord injuries in 24%, and
• aerodigestive tract injuries in 6% of patients with
transcervical injuries.
• The overall mortality was 3%

61. Intermediate care
• Diet and feeding
• Liquid diet
• Nasogastric tube can be used in extensive injury
• When there is loss of oral sphincter saliva shield made of acrylic or silicon can be
used
• gastrostomy if longterm bypass of the oral cavity is necessary
• Oral hygiene
• Mouth wash with antiseptic solution (chlorhexidine )
• Active irrigation with 4% sodium bicarbonate at least once daily
• Brushing by soft tooth brush
• 1% hydrocortisone ointment applied regularly to the lip
• Control of infection
• Prophylactic antibiotic to prevent infection especially septicemia,meningitis and
pulmonary infection
• To prevent secondary hemorrhage
• Infection of fracture site : controlled by intermediate surgery to remove teeth or
sequestra with drainage of pus if present and do culture and sensitivity test to
advocate the appropriate antibiotic
• Early mobilization and physiotherapy to prevent thrombophlebitis

62. secondary or late Reconstruction
• Timing of definitive reconstruction is an area of continuing
debate. Although traditional approaches advised delayed
reconstruction, recent studies demonstrates success with
more immediate definitive reconstruction within 24–48 h.
• Advantages of early repair:
1. immediately reducing local dead space
2. immunoreactivity is improved,
3. more robust biologic coverage is provided, and
4. delivery of hematogenous nutrients essential for wound
healing is enhanced. Furthermore, fewer and less complex
revisionary procedures are necessary for patients who
underwent immediate definitive reconstruction

63. 5.superior aesthetic and functional outcomes,
6.There is no soft tissue contracture or deformity in primary
treatment, in addition coverage of soft tissue defects is easier
and more anatomic.
7.Ease of reduction and fixation of fractures, easier restoration of
occlusion, prevention of contracture and displacement, ability to
reduce displaced or avulsed teeth, early mandibular mobilization,
8.less scarring, less anxiety and shorter hospital stay are among
the many benefits associated with comprehensive definitive
management of maxillofacial gunshot injuries in the first surgical
intervention.

64. Soft tissue reconstruction
• Primary closure
• Reconstruction of soft tissue
should precedes hard tissue.
Local flaps:
Colour and texture matching
is best done with local flaps..

65. tissue expansion
• In the case where tissue expansion is
desired, the wound should be maintained
by dressing changes or vacuum-assisted
therapy or covering with temporary skin
graft until tissue expansion is complete.
This approach accomplishes both wound
conditioning providing adequate amount
of local tissue needed for transfer without
adversely affecting the donor site. A
combination of both microvascular and
local flap techniques may be necessary for
the repair of severe defects.

66. •
• Free tissue transfer: Some massive soft tissue defects
secondary to gunshot wounds require free tissue transfer.
Over the past decade, advances in microvascular technique
have established free flap transfer as the gold standard in the
reconstruction of severe facial trauma; however, they are not
used primarily.
• In cases that require multiple stage reconstruction, the free
flap option is often best delayed until the exact nature of the
defect is diagnosed and the patient is best prepared for this
intervention

67. Facial unit reconstruction
• Tissues available for reconstruction of face may be derived
from various sources. Some of the easily available flaps are:
• Forehead flap: central, lateral, scalping/converse
• Neck
• Hairy scalp
• Post-auricular
• Delto-pectoral
• Myo-cutaneous : pectoralis major, latissimus dorsi, trapezius
• Free flaps
• All these can be grafted with micro-vascular anastomosis
whenever possible and facilities are available.

68. • Principles of reconstruction in these cases are:
• Each aesthetic unit, if possible, should be separately reconstructed
to avoid simple flat surface devoid of shape.
• Each functional layer should, if possible, be reconstructed separately
– e.g. lining, muscle, fat and skin.
• An excess of tissue should always be introduced to restore
symmetry. Shortage of tissue can only be corrected with a further
flap. Excess fat should be transferred to allow subsequent fat
sculpting.
• The best tissue match should be sought, keeping in mind the
inevitable defect in the donor site.
• A careful plan of the staged procedure should be prepared to reduce
the time and number of procedures to the minimum, and to allow
continuity by various members of the team.
• The stages of reconstruction should, where possible, not limit the
patient’s ability to see, breathe or feed.
• Soft tissue reconstruction is best achieved on a sound skeletal base.

69. Hard tissue reconstruction
• Restoration of anteroposterior projection and width of the
face should be the primary goal of skeletal reconstruction.
• When a mandibular fracture is a component of gunshot
wounds, re-establishing mandibular continuity and thus
restoring occlusion first is advisable.
• Some authors now advocate doing immediate bone grafting
for nasal, orbital and mid-face areas and secondary, but early
bone grafting of the mandible

70. Bone grafts
• These are now commonly used in the reconstruction of 1.
Mandible .2. nasal skeleton, 3. Onlay graft to the supra orbital
region, 4. After surgical treatment of RMJ ankylosis 5. Repair
of oro-nasal or oro-antral fistula
• Bony defects larger than 5 mm should be bone grafted.
Depending on the nature of these defects, iliac crest, cranium
and rib are all reasonable options.
• In most cases, vascularised bone is not critical for
reconstruction

71. • Distraction Osteogenesis: - complex composite defects in the
partially dentate patient,
• . To facilitate distraction, soft tissue reconstruction and
healing should be complete to ensure integrity of the wound.
• well-observed benefit of distraction is the increase in native
soft tissue.

72. Management of special structures
• FACIAL NERVE: occurs in high velocity firearm injury.
• early documentation is important
• obvious transection requires repair.
• In heavily contaminated wounds, repair should be delayed for
48-72 hours.
• Injuries distal to the zone of arborization (vertical line dropped
from lateral canthus) do not typically require repair because
of multiple interconnections distal to this line. Function is
expected to return.

73. Salivary ducts
• Transected duct may be repaired or ligated depending on the
amount of damage. Parotid duct can be repaired over an
intravenous catheter or polymeric silicon tubing, which is then
sutured to the buccal mucosa, without bringing it out into the
mouth, to prevent its dislodgement. Injuries to parotid-
masseteric fascia may cause formation of a sialocele or
fistula, managed by drainage and pressure dressing.
Aspiration may be required and anti-sialogogues may be
prescribed. Foreign bodies must be removed to hasten
healing.

74. Residual problems and their management
• MICROSTOMIA: destruction of lip tissue causes severe fibrosis
and reduced opening of mouth. This has to be corrected
before any attempts to correct mastication and facial
appearance.
• Cheiloplasty is necessary for taking impressions and
construction and insertion of prosthesis.

75. • Reconstruction of lacrimal injury:
• the obstruction has to be located with probe and, exposed. A
fine silastic rod is passed through the duct into the nose and
kept in place with stiches for 3 months.

76. • FIBROUS AND BONY ANKYLOSOS OF MANDIBLE:
• comminuted fractures of condyle, ramus and adjacent maxilla
and zygoma frequently result in intra or extra-articular bony
or fibrous ankylosis. Costo-chondral grafts may be used for
reconstruction of RCU after release of ankylotic mass.

77. Oro-antral and oro-nasal fistulae
• Closure of a residual fistula is important for adequate
functional restoration.
• Single layer closure usually sufficent for oro-antral fistula with
or without nasal antrostomy for antral drainage.
• Oro-nasal fistulae are more difficult to close and single layer
closure does not succeed. Nasal lining is used for a two layer
closure. Bone chips may be transposed between the two
layers. Larger fistulae may be repaired with palatal
transposition or island flap, tongue flap and skin flaps from
naso-labial folds.
• Very large defects need obturators

78. SCAR REVISIONS AND RELEASE OF CONTRACTURES:
• Although recent reports link early definitive reconstruction
with a decreased need for revision surgery, a majority of our
patients still request some form of revision.
• Tattooing can be removed with Nd;YAG laser but not for
dermal inclusion of gunpowder for them use minipunch.

79. Using implants and prosthesis:
• .These implants of 3, 4 and 6 mm length become osseo-
integrated into bone local to the defect and serve as anchors
for a nose, eye or ear prosthesis.
• They may be attached to the prosthesis by a clip-bar
arrangement or via gold-samarium magnets. Hence the
patient enjoys a morphological and cosmetic prosthesis that
does not fall off even with strenuous activities.

80. • NASAL PROSTHESIS
• 3 implants are placed like an isosceles triangle (2 at alar base
and one at the bridge of nose). The nasal passage may be
opened by placing a tracheostomy cannula adapted to the
connecting bar. This allows nasal breathing without coming in
view.

81. Ear prosthesis
• 3 implants are placed into the mastoid bone along 110o arc
from the anticipated external ear canal. Implants are short (3-
4mm) to prevent perforation of dura. They osseointegrate
within 4 months and the ear prosthesis is attached with
magnets.

82. Eye prosthesis
• implants of 6-8 mm are placed in either lateral superior orbital
rim or inferior lateral orbital rim. They also osseointegrate
within 4 months.
•

83. • All external facial unit prostheses undergo wear and fading of
their original color.
• This process can be slowed by limiting their direct exposure to
sunlight and heat.
• They should also not be allowed to come into contact with
strong chemicals. Simple light soap solutions are best to clean
these prosthesis.
• On a yearly basis these prostheses need to be examined and,
often, refitted with new clips, material added to frayed edges,
and partly repainted to restore their natural-appearing colors

84. Summary:
• Gun shot injury to face in civilian violence is a benign condition
as long as the patient’a airway is kept patent and
haemorrhage is controlled.
• Early operative intervention for repair of soft and skeletal
facial structures leads to satisfactory results.
• mortality directly related to the facial trauma is uncommon.
Improvements in imaging and fixationtechniques have
resulted in an evolutionin management, with an emphasis on
earlierrepair and a focus on improvement inquality of life.

85. REFERENCES:
• Peterson’s principles of oral and maxillofacial surgery: volume 1
• Raymond Fonseca: oral and maxillofacial surgery : volume 3
• Rowe and Williams: Maxillofacial Injuries: volume 2
• Maurizio A. Miglietta: Trauma and Gunshot wounds: What you need to know to save a life.
• Orthopaulis G, Sideris A, Velmahos E, Troulis M: Gunshot wounds to face: emergency
interventions and outcomes: World J Surg (2013) 37:2348-2352
• Management of comminuted but continuous mandible defects after gunshot injuries Majeed
Rana etal Injury, Int. J. Care Injured 45 (2014) 206–211
• Characteristics of Ballistic and Blast Injuries David B. Powers Atlas Oral Maxillofacial Surg Clin
N Am 21 (2013) 15e24
• Craniomaxillofacial Battle Injuries: Injury Patterns, Conventional Treatment Limitations and
Direction of Future Research ,Robert G Hale, Timothy Lew and Joseph C Wenke; Singapore
Dental Journal ■ June 2010 ■ Vol 31
• Craniocerebral Gunshot Injuries in Civilian Practice-Prognostic Criteria and Surgical
Management: Experience with 82 Cases.HUBSCHMANN, O. M.D.; SHAPIRO, K. M.D.; BADEN,
M. M.D.; SHULMAN, K. M.DJournal of Trauma-Injury Infection & Critical Care: January 1979

86. • Journal of Trauma-Injury Infection & Critical Care:
• May 1996 - Volume 40 - Issue 5 - pp 758-760
• 11.Shootings: What EMS Providers Need to Know
• by Paul Murphy, MS, MA, EMT-P, Chris Colwell, MD, FACEP, Tamara
Bryan, BS, EMT-P, Gilbert Pineda, MD, FACEP On Apr 1, 2010
• 12..Computed Tomography in the Evaluation of Penetrating Neck
Trauma: A Preliminary Study
• Vicente H. Gracias, MD; Patrick M. Reilly, MD; Jonathan Philpott,
MD; Wendy P. Klein, MD; Sun Y. Lee, MD; Michael Singer, BS; C.
William Schwab, MDFrom the Divisions of Traumatology and
Surgical Critical Care (Drs Gracias, Reilly, Philpott, Lee, and Schwab
and Mr Singer) and Radiology/Body Imaging (Dr Klein), University of
Pennsylvania School of Medicine, Philadelphia.
• Arch Surg. 2001;136(11):1231-1235.
doi:10.1001/archsurg.136.11.1231