Comprehensive Management of Maxillofacial Projectile Injuries at the First Operation; “Picking up the Pieces”

Copyright © 2013, Trauma Research Center.; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The issue of when to treat maxillofacial firearm injuries with regard to timing (early or delayed), remains an issue of debate (1-4). Although not all maxillofacial projectile injuries can be comprehensively treated at onset, many indeed may (1-4). In over 50 cases of firearm injuries to the face at our center, more than 30 were treated via early comprehensive repair and simultaneous open reduction for maxillofacial fracture fixation. These patients underwent primary debridement and arch bar placement followed by open reduction of fractures (with or without osteosynthesis) followed by primary wound closure. Primary comprehensive intervention was done when there was no gross infection, no bone comminution, no extensive soft tissue avulsion (preventing wound coverage), and when general health, concomitant injuries requiring more urgent attention, or those requiring major grafts did not preclude this. Primary management included extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), brushing, debridement of the facial wound, removal of floating fragments (teeth particles, debris, and shell fragments) excluding viable bone within the wound. Next, after access to the remaining bone stumps, we sought to find scattered bone segments; after that we put them back into place to restore bone continuity (especially in the mandible) similar to “Picking up the Pieces” and putting together a puzzle (Figure 1). This is often possible more often than not because the bone is usually shattered and scattered, rather than avulsed or pulverized (5).