DEPARTMENT OF

ORAL SURGERY AND SURGICAL ORTHODONTIA

U nder E di torial Supervision of

M. N . Federspiel , D.D.S . , M.D.• F .A. C. S. • Milwaukee.- V ilray P. Blair , M .D. ,F .A. C. S., St. Lou is, Mo .- Arthur E. Sm ith, M. D., D.D.S. , C hicago .- WilliamCarr , A.M ., M.D. , D .D.S. , New York.-R. Boyd Bogle . M .D. , D.D .S., Nashv ille.- Major Joseph D. Eby , D .D .S. , Atlanta.-Thos. P. Hinman , D.D.S. , Atlanta.­Arthur Zentler, D .D .S ., New York.-Leroy M. S. Miner , M .D. , D.M.D., Boston.

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AN ANALYSIS OF GUNSHOT INJURIES TO THE FACE

By V. H. K\ZA1'oi]IAN, C.M.G., D.M.D., BOS'l'ON, MASS.

Dem onstrator of Prosth et ic Dentistry, H aruard UlIit '('rsity Dental S cho ol

TH E great maj ority of gun shot wounds, except supe rficial cuts and abrasions,a re inevi tab ly associated with th e fac ial bone s, because of the thinness of the

facial musculature and of the large amount of osseous substructure. Though thedamage be but slight, a communication may have been effected with the nasal orthe oral cav ity , th e an tra, sinuses, or pharynx. Th e am ount of injur y as a resul tof gunshot wound, which the soft or hard tissues suffer beyond the entrancewound, is in th e first instance the res ult of the speed, shape, and str iking angle ofthe piece of metal, and in the second instance the re sult of the bony fragmentswhich act as secondary proj ecti les, wit h almost explosive violence. These forcesmay cau se a la rge pat h and an extensive wound of exit in the tissues; yet th eactual destruction or comp lete tearing away of subs ta nce is usually not presentto any marked degree, and the severed borders of the wound may be traced. Theexaggera ted size of th e wound is due to the cont raction of th e severed mu sclestoward their origins and insertions, to the local in flammation , and to the weighto f the sha tte red pieces of bone. A lar ge nu mber of facial wounds are seen witha small entrance and a small exit. T he severity of such wounds depends alm ostentirely upo n th e anatomic location and the path of the piece of meta l. T hrough­and-through wounds of the anterior part of the fac e may ca use ex tensive de­struction of the teeth and comminution of the bone, but in the main do not leadto alarming complica tions provided adequate treatment a t an early period iseffected. Contrary to this, however, wounds involving the poster ior par t of thefa ce, espec ially th ose of the pharyngeal, carotid, and lower molar regions, a reparticularly da ngerous. Such injuries may cau se bilateral frac ture of the mandi ­ble, and in many cases may be situated near enough to important blood vessels toinsure a probable chance of severe hemorrhage.

98 The International]ournal of Orthodontia and Oral Surgery

The tongue, since it occupies almost the entire oral cavity when the mouth isclosed, is liable to serious injury along with either the upper or the lower jaw.If the wound be limited to its apex or dorsum, its abundant blood supply promotesrapid healing in spite of severe laceration or even sloughing; but, if it be pene­trated about its base, serious hemorrhage may ensue through involvement of thelingual arteries. Fragments of bone and teeth are apt to bring complicating fac­tors, if driven into the tongue: they convey infections and elude detection orlocalization by radiogram (Fig. 1).

WOUNDS OF THE I,oWER PART of THE FACE

A wound of the lower lip represents a fairly common type of wound in con­nection with which there exists a small wound of entrance, at first obscure, atdifferent points posteriorly, on the neck, cheek or face, leading to symphysis (Fig.2). The lip may appear lacerated with appreciable loss of tissue, or may be

Pig. 1. Fig. 2.

partially or entirely destroyed with attending comminution and destruction atthe mandible at the symphysis. Other fractures of the jaw may occur a~ the resultof transmitted force.

There are seen hideous, gaping wounds of the lower lip, chin, and even thesublingual region, which communicate with the oral cavity and which are ac­companied by severe injury to the bone: but in many instances these are but ex­tensive tears in the soft tissue, do not involve a loss of substance, and consequentlylend themselves favorably to suturing at the proper stage in the treatment of thecase (Fig. 3).

There also occurs a type of wound less commonly which is serious and ex­tensive, involving laceration and destruction of the lower lip, chin, sublingualregion, and even the upper aspect of the neck. These have a characteristic ap­pearance and require special consideration since in addition to the mutilation ofthe soft tissues there usually occurs serious loss of the mandible (Fig. 4).

A n <'Jill/lysis of Gunshot Injuries of the Face 99

WOU NDS OF THE UPPER PART OF THE FA CE

Injury of the upper lip is quite commonly seen and va r ies in extent fromlaceration and slight loss of tissue to a complete destruction involving the lowerpart of the nose.

F ig. 3.

Fig . S.

Fig. 4.

Fig . 6.

The more serious wounds of the upper part of the face may include a partor the whole of the nose, the eyes, the ears, and the zygomatic region. Themaxi lla is apt to suffer grea t comminution and considera ble loss of bone in case

100 The International Journal of Orthodontia and Oral Surger)'

of injury of this type. The loss of the upper lip is invariably associated withmutilation of the anterior part of the maxilla, at times as far posteriorly as the

Fig. 7.

Fig 9.

Fig. 8.

Fig. 10.

molar regions, and in some rarer instances practically the entire maxilla, andthe septum of the nose may be carried away. The involvement of one or bothantra is common, and might almost be said to be a certainty (Figs. 5,6, 7 and 8).

An A nalys is of Gunshot Injuries of th e Fa ce 101

A lacerating wound of the cheek, jf at all sever e, communi cates with th e oralcavity and in many instances is sufficiently extensive to involve the angle of themouth, the lips, the eye, the ear, and the lateral aspect of the neck . Usually thereis free exposure of the bony substru cture, mandible, maxilla, and zygomaticprocess (Fig. 9).

Wounds high on the cheek, if anything more than an abrasion, are practicallycertain to involve the ascending ramus of the mandible, the temporomaxillaryarticulation, and the parotid glan d, and furthe rmor e obviously give ri se to pa­ralysis of the side of the face which is injured. In the ex treme instances the in­jury includes the ma stoid regi on and the base of th e skull (F ig. 10).

£FF£CT OF F.\ CI AL WOU N DS

The high degree of vascularity of the face give s opportunity for free primaryhemorrhage following gunshot wound. The wounds become inflamed and speed­ily septic because of th e presence of organisms in the nasal and oral passages.

Jn the event of gunshot wound of th e face and jaw the patient undergoesconsiderable pain and physical and mental rcaction-; and furthermore suffers greatinconvenience through the impairment of the most natural of functions; chewing,swallowing, breathing, speaking and the retaining of saliva . In spite of the pecu­liar disadvantages which accompany the wound, however, fav orable progress to­ward recovery is made (l ) becau se of the rich blood suppl y to the parts affected(2) because of th e free flow o f saliva which, though teeming with organi sms,nevertheless maintains a slow and persistent mechanical irrigation of the woundand prevents the tissues from becoming dried and encrusted with blood, pus, andfood particles, and (3) because of the opportunity for drainage to the nasal ororal cavity independentl y, if necessary, of the usual external drainage.

Fr XATJO N OF 'f H E n o xv PARTS

In order to discuss clearly the que stion of splints and appliances used in thetreatment of wounds of the face and jaw , an ana lysis o f the natu re of the bony'injury is necessary, as compared to the ma xillary fractures seen in civil ian life.Thi s latter type, usually the re sult of a fall, a blow, an accident, kick, and so on,and usually referred to in discu ssion as "accidental" without definite regard totheir cau se, is serious at times and may be compound, but is fr ee from actual bonydestruction except in the instances when teeth and their surrounding alveolarprocess are knocked loose. The lines of fracture are irregular, but well defined,and the displacement is less pronounced than in the case of war injuries. Thehealing proce ss is as a rule more rapid and une ventful , though at times it is diffi­cult to reduce the displacement properly, becau se of the fact that the irregularends at the site of fracture, being but slightly comminuted, have a tendency tointerlock. The patient suffers considerable pain and inconvenience, and mildcomplications such as localized inflammation and abscess; but beyond the se themore serious complications do not usually occur except in the event of inadequateor delayed treatment.

But when the fracture of the jaw is th e result caused by a bullet or otherweapon of warfare, comminution and a definite, though perhaps slight, destruction

102 The I nt ernational Journ al of Orthodontia and Oral Surgery

of bony tissues exists. Such injury may be confined to the teeth and alveolarridges and not seriously or materially impair the continuity of the bone , while inoth er instances a lar ge porti on or the whole of the upper or th e body of the lowerjaw is blown away. In extreme cases it is often found that th e injury ha s includedth e whole of the nose, th e tongue, the sublingual region, or the ent ire lower partof th e face.

The site of f ractu re follo wing gunshot wound is not charac1eri zed, as is truein accidenta l cases, by an irregular line, but by multiple lines of fracture whichradiat e in many directions. The mobility of the pa rts is fr eer, and there is littleor no tendency on the part of the segments to inte rlock rigidly. The pronouncedmobility and displacement of the segments of bone is increased by the exten sivelaceration of the overly ing soft tissues.

In the majority of cases the likelihood of grave complications confronts theattending surgeon. And in addition to the suffering cause d by wounds of theface and jaw, as described, and the anxiety of the possibility of serious compli ­cat ions, it is the rule rather than the exception that the fortune of modern warmade the pat ient the recipient of wounds of other part s of the body, wounds whichneed a separate scheme o f treatment and which give rise to different symptomsand discomforts.

CO;\r PAR ISo N OF I M MEDIATE AN D GRAD UAl, IM ~IO BI L IZATION

Dur ing th e period of th e wa r many advances were made toward th e perfectionof th e applian ces used in the treatment of maxillary fractures, and many ex­t remely ingenious devices were offered to the profession. To the casual observerthere might appear to exis t a complexity and confusion of appliances; but mostof them in one way or another have served a purpose. All fa ll into two distin ctclasses, according to the intended obje ct in their adaptation: ( 1) appliances andsplints designed for the immedia te fixation of the fr agment s, and (2) app liancesand splints construc ted to cau se gradual redu ction of bony displacement and de­formity.

As previously described, the wound in th e first days following injury is in­flamed and septic, and the bony tissue after fractu re is in extreme displacement,and mobile and poorly supported. At this stage it is impo r tant to note that a rigid­ity of the tissues brought on by contraction and scar formation has not yet oc­curred. As the sepsis and inflammation subside, so healing begins and sequestraare exfoliated, and the bone either consolidates to some extent or becomes firmerin a defor med position in the soft tissues.

Immediatel y, or soon after the time of fracture, the segmen ts respond easi lyto mani pulation , and the reduction of displacement is possible wit h tile fr agm entsmaintained in correct position and alignment by compara tively simple splints;but if the immobilization of the bony parts is left until that later period when thef ragments resist reduction because of the fact that healing has begun, then it isobvious that splints and appliances of a more complicate d construction are needed .

It has been proved beyond doubt that the fanner meth od-namely, that ofimmediate or earl y fixation of the bony parts-is pref erable, even though the

An Analysis of Gunshot I njuries of the Face 103

days just a fter injury are cri tica l for th e patient. So far the advantage of earlyfixati on has been emphasized only fr om th e mechani cal viewpoint ; bu t it is ofequal importan ce to note that th e immobilizati on of the bone and the reductionof the fractu re have lessened the size of the wound and consequently diminishedthe irritation and infla mmation of the so ft tissues, a nd that there has been utilizedthat brief period of time in th e progress of a case which precedes th e onset ofserious complications, should any occur which would prohibit work incident tothe ad aptation of splint s. T he pa tient is also rendered more com fortable, and ishappier becau se he fee ls tha t something has been done to set him on the road torecovery.

Fig. 11.

In order to carry out a successful techn ic for the immediate fixa tion ofth e bony tissues, the fo llowing requ irements are essentia l:

1. The proced ure adopted mu st be sufficiently simple to make possible th etreatm ent of a large number of cases, The dental mechanics attached to th edepartment mu st have the fac ilities to make a large nu mber of appli an ces easily,rapidly, and accurat ely, and also must have in a partial state of compl etion suchapp liances as head gears, metal bands fo r the teeth , etc, P romptness in th e con­struction of splints is an essential factor in a scheme for immediate fixati on.

104 The International Journal of Orthodontia and Oral Surgery

2. The actual adjustment of the completed appliance must be sufficientlysimplified to cause the minimum amount of pain to the patient. In view of thegeneral condition of the wounded man, it is often advisable or necessary thatminor operations, impression-taking, and other details incident to the constructionof appliances be done at the bedside. For any step in the preparation and ad­justment of the splint there is never justification for the use of a general anes­thetic.

Private B was wounded on June 10, 1917, and admitted to the hospital onJune 12, 1917.

There was a large lacerating wound of the lower part of the face extendingfrom the right corner of the mouth to the submental region (Fig. 3). Themandible was severely comminuted, from the mental to the first molar region,with marked downward and inward displacement of fragments (Fig. 11), es-

Fig. 12.

pecially at the site of the external wound. There was great laceration and in­flammation of the oral mucous membrane. In addition, the patient was sufferingfrom a wound on the right shoulder and on the left leg.

The general condition of the patient was fair. He was coughing quite freelyand the temperature fluctuated up to 1000 for a few days. Otherwise he wasquite comfortable.

On June 17, the mouth was cleaned surgically by removing some sloughedand necrotic tissue, useless and loose teeth, and pieces of bone. There remainedin the mouth two sound molars on each side of the jaw. Over those molars aband and arch splint was secured, giving anatomic relations of the remaining partsof the mandible. A vulcanite removable appliance was fitted to the arch of thesplint, to give proper labial fullness and to prevent adhesion to the alveolarprocess during the process of healing.

A n Analysis of Gunshot I njuri es of the Face 105

On June 27, the woun d was fairly clean , the edema and inflammation havingdisappeared ( F ig. 12). The soft tissues were sutured.

The operation was performed under novocaine ane sthe sia.

1. The border s of the wound wer e exci sed.

2. The borders of the mucous membrane were approximated and suturedwith catgut.

3. The borders of the skin could not be brought together on account ofgreater laceration of the ex te rnal sur face of the wound, and therefore a skinflap was turned from the right side of the fac e to cover the gap . ( See Fig. 13.)A small drainage tube was insert ed at the base of the wound.

"

Fig. 13.

On October 17 and 19 it was necessary to open abscesses in the sublingualregion, which were attributable to small seque stra of bone still to be exfoliatedor remo ved by operation.

An x-ray picture showed that the lower right first molar was sufficientlyinvolved in the region of fra cture to hinder pr ogress. T his tooth was removedand a new splint of the same type as the former was cemented to place.

On November 1 the scar left by the drainage tu be at the lower bord er ofthe wound was removed.

On November 19 the patient was transferred to England. All suppur ationhad ceased, the scars were very slight, and bony union was progressmg 111 asatisfactory manner (Fig. 14).

106 Th e I nt ernationai Journal of Orthodontia and Oral S urgery

Ski pper Privat e S was wounded on July 31, 1917, and admitt ed to hos­pital on August 2, 1917. There was a large lacerating wound extending fromthe left angle of the mouth to the angle of the mandible. The left side of the

Fi~. 14.

Fig. 15.

L_Fig. 16.

ton gue was injured and inflamed, and attend ed with partia l pa ralysis due toinvolvement of the hypoglossal nerve (Fig. 9 ).

The mandible fr om the left cuspid to the ascending ramu s was comminuted,

An A nalysis of Gunshot Injuries of the Fa ce 107

with free exposure of the resulting fragments of bone and downward displace­ment. All the teeth of the right side of the upper jaw were destroyed. OnAugust 8 a cap splint was cemented to the teeth of the lower right side, withan arch wire extending over the injured area of the left side. To the latter fourfragments were suspended by fine wire sutures. An upper cap splint was cementedto the remaining sound teeth of th e maxilla, and the lower jaw was thus im­mobilized by intermaxillary ligation bet~een the two splints. On August 13

Fig. 17.

Fi g. 18. I'i g. 19.

the wound of the face was partially sutured (F ig. 15) , leaving the part near thecorne r of the mouth to granulate because of a distinct loss of tissue at that point.

Fig. 16 shows th e condit ion of the patient on September 3, when a secondoperation was perform ed. The scar on the face was removed, and the missingportion at the left angle of the mouth wa s supplied with a small rectangular flaptaken from the left side of the upper lip. The red bord er of the lower lip wasfreed and st retched to cove r the raw surf ace of th is flap ( Fig. 17, 18 and 19) .

108 The International Journal of Orthodontia and Oral S urgery

O n October 29 a small operation was necessary, to mak e further improve­ments in the lef t corner of the mouth. One of the larger fragments of the jawwhich was suspended to the splint was exfoliat ed, and fr om time to time othersmall sequestra came away; but at the time of dismissal of the patient, Janu-

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ary 10, 1918, the re was a healthy bony growth of the mandible except for aspace of about one-half inch at the angle, where fibrou s tissue ex isted. T he re­maining teeth on the r ight side were in good occlu sion with the upper teeth , andthe fa cial scars were rapidly disappear ing. The final condition bef ore dismissalis shown in Fig. 20.

~11 A nalysis of Gunsho t I njuries of the Fa ce 109

Private M received wounds of the face and shoulder on Septem ber 15, 1916,an d was admitt ed to hospital on Se ptember 18. T he upper lip was alm ost com­plet ely destroyed, and the right cheek and right portion of the lower lip werelacerated (Fig. 5) .

The maxilla was comminuted with loss of tissue ante r ior to the molarregions, .with acc ompanying dest ru ction of th e floor of th e right antrum. Thelower jaw was intact.

In accorda nce with the general treatmen t of the case, minor operations werenece ssary to remove slough ing tis sue and to remove useless and loose teeth andpa rticles of bone. A few sti tches were inserted to su pport the mucous membrane,and a rubber tube was used to dr ain the region of the r ight ant ru m.

A few days a fter the patient was admitte d to the hospital , a vu1canite splintatt ached by cla sps to the molar teeth was used to mould the maxillary tissue

Fig. 24, Fig . 25.

and to preserve the contour of th e remaming buccal and labial tissues. Thisvulcani te plate, or splint, is essential to the repairing of th e ti ssues, and is wornvery early in the treatment even if it comes in conta ct with raw surfaces.

O n O ctober 17 the inflammat ion of the fac e had subsided sufficiently to a l­low suturi ng o f the buccal portion of the wound with local anes thes ia. The rul esad opt ed for sutur ing are as follows: If the so ft ti ssue s are lacerat ed, but sufferno destru ction , th en the borders are approxima ted and sutured as soon as in­flammation has been redu ced. But, if there is a loss of soft tissue, only radiat­ing port ions of a wound respond to ea r ly suturi ng, while closure of the woundas a whole is post poned until suppur ation, inflammation an d contraction haveceased. In addition , the general condition of the patient mu st be satisfactory atthe time of operation .

In thi s case recorded the radiating portions of the wound were sutured earlyin the treatment , a nd on J anuary 9, 1917, und er local an esth esia , rectangular flaps

110 The International Journal of Orthodontia and Oral Surgery

were taken from the upper part of the face (see Figs. 21, 22 and 23) to formthe upper lips, and thus finally close the wound. On February 2 the border ofthe upper lip was trimmed to make it shorter, and the margin of the mucousmembrane was improved. At the same time the lower lip was shortened, to pro­cure harmony with the upper lip, by removing a small triangular piece at themedian line. The patient was supplied with an 'upper denture and evacuated toEngland on March 15, 1917 (Figs. 24 and 25).