Vol 21 No. 1

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J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for... mucoperiosteal attachment and its blood supply to the osseous fragments in open procedures). Closed reduction and indirect skeletal fixation was used as the modality of choice in this study for all cases. Arch bars (Erich pattern) applied due to their avaliability, ease of application and shorter operation time. Displaced fractures were treated initially with interarch elastics applied to the arch bars (Figure 2), and it was noted that fracture displacement will be reduced wihin short time (5 minutes) provided that it was applied in the right way (no crossing). Complications were common in these series with 17 out of 32 patients experiencing one or more complications 53.1%, this high complication rate was acceptable since many of complications were transient. There is a relatively high rate of wound infection in this study 16.2% compared with Zaytoun et al (31) (24) 12% and Akhlaghi & Aframian-Farnad 11.4%, this high rate may be explained that many of missile injuries could not be treated in a strict aseptic techniques which were not always possible in the event of mass casualities due to hospital facilities. The incidence of significant bone loss was 35.13% in 13 patients who subsequently require the use of autogenous bone graft. Chambers & Scully (32) reported a less incidence of bone loss from the mandible 27.5% in 16 out of 58 patients with missile injuries. The loss is related to the high energy imparted at impact and to the effect of shock wave and temporary cavitation produced by high velocity missile resulting in extensive tissue damage. Fracture of the mandible within the course of inferior alveolar nerve frequently results in nerve injury and altered neurosensory function; this may be due to direct injury or secondary injury due to the line of fracture or missile path or a secondary insult due to manipulation and temporary reduction of the fracture. The predominant sign was paraesthesia in the lower lip and chin regions in addition to the gingiva and teeth which was found in 32.4%. The degree of nerve injury determine whether the impairement of sensory function being transient or permanent. Occlusal abnormalities reported in 6 patients 16.2% in which minor or gross abnormalities were seen, this may be due to severe bone destruction under the influence of muscle pull or simultaneous severe bone destrucion to upper jaw and teeth. Minor discrepancies may be acceptable or can be corrected by selective grinding of teeth, while gross abnormalities require further treatment (Figure 5). Figure 1: 3-d reconstruction life-size model of facial bones made from CT scan image, amount of bone loss can be accurately estimated. Figure 2: (A) Postoperative view showing comminuted fracture of left mandibular angle. (B) Closed reduction utilizing arch bars & elastic traction. (C) Frontal view 3 months after injury. (D-E) Postoperative occlusal relationship, note the nice occlusion result. 95 Oral and Maxillofacial Surgery and Periodontology
J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for... Figure 3: (A) Transverse perforating missile injury. (B) Postoperative OPG showing bilateral fractures (comminuted right body) treated by closed reduction using arch bars. (C) Axial CT scan demonstrating bilateral fractures (arrowed). (D) Frontal view showing reasonable occlusal relationship. (E) Acceptable mouth opening without limitation at the longest follow up. (F) Outlet side healed by secondary intention, note the bony prominence at the lower border. Figure 4: (A) Bullet injury causing bilateral multiple comminuted fractures with massive tongue injury decussating urgent tracheostomy & nasogastric tube feeding. (B) Lateral radiograph demonstrating severe downward & posterior displacement of the anterior mandible. (C) Postoperative panoramic view demonstrating the acceptable lower border. 96 Figure 5: (A) Avulsive injury caused by high velocity missile with extensive disruption of bone & soft tissues. (B) Postoperative view showing comminuted fracture of the left angle region of the mandible. (C) Three months after treatment with fair results and adequate mouth opening, note the residual defects (loss of premaxilla, loss of part of the upper lip and deformity of fractured nose) need further reconstructive surgery. REFERENCES 1. Owen-Smith MS. High velocity missile wounds, London, Edward Arnold, 1981. 2. Jacobs JR. Maxillofacial trauma: an internationalperceptive, New York, Praeger, 1981. 3. Amoto JJ, Billy LJ, Lawson NS. High velocity missile injury: an experienced study to the retentive forces ot tissue. Am J Surg 1974; 127: 454. 4. Whitlock RIH & Kendrick RW. Treatment of maxillofacial injuries in various theatres of war, text book of maxillofacial injuries, vol.2, 2nd ed, Churchill-Livingstone, 1994. 5. Mellor S. Gunshot wounds, text book of maxillofacial injuries, Vol. 2, 2nd ed., Chuchill-Livingstone, 1994. 6. Banks P. Gunshot wounds, text book of maxillofacial injuries, vol. 2, 2nd ed., Churchill-Livingstone, 1994. 7. Rowe N & Williams J. Mandibular fractures, treatment by closed reduction and indirect skeletal fixation, text book of maxillofacial injuries, vol. 1, 2nd ed., Churchill-Livingstone, 1994. 8. Yetiser S & Kahramanyol M. High velocity gunshot wounds to the head & neck: a review of wound ballistics. Mil Med 1998; 163: 346-351. 9. Barber HD, Woodburg SC, Silverstein KE, Fonseca RI. Mandibular fractures, text book of oral & maxillofacial trauma, vol.1, 2nd ed., W.B. Saunders Company, Philadelphia, 1997. 10. Thaller SR. Management of mandibular fractures. Arch Otolaryngol Head Neck Surg 1994; 120:44. 11. Assael LA. Rigid internal fixation of facial fractures. Principles of oral & maxillofacial surg (2nd ed), PA. Lippencott-Raven, Philadelphia, 1997; 357-360. 12. Luyk NH. Principles of management of fractures of the mandible. Principles of oral & maxillofacial surgery, 2nd ed., Lippincot-Raven, Philadelphia, PA, 1997, P.424. 13. Banks P. Killeys fractures of the mandible, 3rd ed., Wright- Bristol, 1983. 14. Goldman KE. Fractures, mandibular, condylar and subcondylar; e Medicine, Last updated: Nov/15, 2006 (internet) http: || www. e Medicine. Com. Oral and Maxillofacial Surgery and Periodontology
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