Gun shot wounds

in maxillofacial region

1. SEMINAR ON GUNSHOT WOUNDS 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. N ational 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 : Internal ballistics External ballistics Terminal ballistics Atlas Oral Maxillofacial Surg Clin N Am 21 (2013) 15e24

8. Internal ballistics F orces 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

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 E arliest projectile was a stone or lead ball Over time theprojectile evolved to the conical-shape . F ull-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 High level Mid –level Low level 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:

31. 3 PEAKS OF DEATH There are 3 peaks of death when it comes to deaths following trauma. 1 st 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. 2 nd PEAK: occurs within 6 hours of injury and stems from internal bleeding and brain swelling. 3 rd 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 E dema 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 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 should be used for fresh water wounds or salt water wounds can be used if allergic to cephalosporins or clindamycin Doxycycline and ceftazidime 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 T he 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 110 o 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