Vol 21 No. 1

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J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for... MATERIALS & METHODS Patients' age & gender The study discuss and prospectively review the results of 32 dentulous patients derived from population of patients with missile injuries admitted at the oral & maxillofacial surgery department at Al-Yarmouk Teaching Hospital in the period between october 2006 – october 2007.The extremes of patient age ranged from 21-58 years. Diagnosis Diagnosis of mandibular fractures based on clinical and radiographic examination. Clinical examination of the face included extra and intraoral examination. The local examination was done to diagnose or exclude the presence of mandibular fractures. Extraoral examination achieved by inspection for the presence of swelling, ecchymosis, bleeding, soft tissue laceration, changes in facial contour, limitation or any abnormal mandibular movements. Bimanual palpation of the mandible with both hands to detect any step deformity, tenderness or crepitation on pressure. Compression test was used by the application of gentle compression of the mandible using both hands in two opposite directions under the lower border to elicit pain which indicate mandibular fracture. Intraoral examination was started by inspection for the presence of sublingual hematoma, mucosal lacerations and changes in occlusion. Teeth were examined for quantity, quality and occlusal relationship, gentle manipulation for mobility of fractured segments and displacement. Radiographic examination include the essential radiographs and according to their availability (plain radiographs as posteroanterior view of the mandible, oblique lateral view, intraoral occlusal view), Panoramic view OPG as shown in (Figure 3 and 4), computed tomography CT scans (axial and coronal). Maxillomandibular fixation MMF Closed reduction and indirect skeletal fixation the sole method of treatment, with jaws fixed using arch bars (Erich pattern) as a mean of intramaxillary fixation for the maxilla and mandible (Figure 2), MMF was carried out with soft stainless steel wires (0. 35 mm gauge or 0.4 mm) for all patients. Circumferential wiring used in two cases only for support and elevation of badly displaced mandibular fractures. Immobilization for 6 weeks being the general guideline. Reduction and fixation of comminuted mandibular fractures achieved in 25 cases under local anesthesia and in 7 cases under general anesthesia. All patients were placed on antibiotic treatment (prophylactic or therapeutic for already present infection) with possible use of culture and sensitivity test if possible from the time of admission until five days postoperatively. Osseous union of the fracture was tested clinically after 6 weeks of MMF, tie wires replaced if union is not satisfactory. To follow patients and monitoring for late complications, patients seen every 2 weeks after immobilization for the first 2 months then every month for at least 6 months. RESULTS In this study 26 of the injured patients were males 81.8% (table 1). Patients with age group 20-29 years are mainly sujected to missile injuries as shown in table 2. Mandibular body was the commonest site for comminuted fractures 50% (table 3). Transient and permanent complications showed high rate 53.1% and less than half of patients 40.6% required further reconstructive surgery as shown in tables 5 and 6. There was statistically significance at probability level < 0.05. Table 1: Gender distribution. Gender Number % Male 26 81.8 Female 6 18.8 Table 2: Age distribution. Age group Number % 10-19 year 2 6.2 20-29 18 56.2 30-39 8 25 40-49 4 12.5 Table 3: Number of patients and fracture site. Number of Site of fracture % patients body region angle symphysisparasymphysis Ramus 16 7 6 3 50 21.8 18.7 9.3 Table 4: imaging studies. Imaging study number % Posteroanterior True lateral OPG Oblique lateral Occipitomental Occlusal CT scan 32 32 20 5 4 2 3 100 100 62.5 15.6 12.5 6.2 9.3 Oral and Maxillofacial Surgery and Periodontology 93
J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for... Table 5: 37 complications in 17 patients with 53.1% complication rate . complication number Wound infection Significant bone loss Neurological complication Occlusal abnormalities 6 3 12 6 1 6.2 5.1 2.4 6.2 Table 6: Patients that required further surgery . Number of % of total Site of fracture % patients number Body Angle Symphysisparasymphysis 7 2 4 53.8 15.3 30.7 21.8 6.2 12.5 Total 13 100 40.6 DISCUSSION The majority of missile injuries to the lower face region in this study occurred in the age groups 20-29 years 56.2% this finding concur with most reported series of facial missile injuries of Hollier (20) (21) , Motamedi and Kummoona (22) which show that these injuries were most common in young adult males.The frequency of missile injuries among males 81.2% more far greatly than that for females 18.8%, the reason may be due to the higher activity and males were mostly involved in the outdoor activities in this Arab Society, they were the most target victims for attacks as a result of deterioration in the circumstances at the present time in our country due to occupation. Mandibular body was the most common fracture site 50%, Newlands et al (23) reported the distribution of a total 67 mandibular fractures due to gunshot injuries, in that the body fractures were the most common 38.8 followed by the angle and then the anterior region, while Akhlaghi & Aframian- Farnad (24) found during the Iraq-Iran war that the most common injury site to the mandible was a defect in the anterior region. The mandibular body region comprises a large surface area while condyles and coronoid regions were subjected to fewer fractures due to its smaller surface area. In addition, most of cases were injured from the lateral side which tend to involve the body region rather than other sites, this differ from the battlefield face to face front line conflict in the anterior region of the mandible was the most commonly involved. Missile injuries ranges from gross comminution of the mandible to simple fracture, M.Shaker (25) reported 76.9% in 60 patients of mandibular fractures were comminuted, the high incidence of fracture comminution due to missile injury related to the high energy dissipated from the missile on impact the compact mandibular bone leading to its fragmentation . In this study, the panoramic radiograph was the best informative view in diagnosing mandibular fractures in only single radiograph, however it was used in only 20 patients 62.5% according to the availability in our center, 2 plain radiographs at right angle to each other (poseroanterior and true lateral views) were used for all patients for localization of retained bullets or sharpnells and for diagnosis of fractures. A stereolithographic model as illustrated in (Figure 1) in which a three-dimentional reconstruction of mandibular bone were made from CT scan images in 2 patients to determine the amount of bone loss, these were handheld life-size model of the facial bones made of a plastic resin which were useful in planning treatment and allow our surgeons to estimate the extent of damage to the maxillofacial skeleton and determine the size of mandibular bony defect for subsequent reconstructive procedure with bone graft. CT scan was recommended for only 3 patients due to its cost, time consuming and hospital facilities that limits its use. Numerous series like Chen et al (26) , Deveci et al (27) and Hollier et al (20) advocated early aggressive intervention for one stage reconstruction and open treatment of all involved structures. However several series favor a more coservative approach likes Demetriades et al (28) , (29) Perry & Phillips who advocating nonoperative management of these injuries due to high incidence of infection. Haug & Assael (30) said that a simpler method should be choosen whenever it is as effective as a more invasive one. We preferred the conservative approach in treatment and reserve the complicated reconstructon for later, the traditional and most proven approach was to use the simplest, inexpensive and most direct feasible method for fracture reduction, fixation and immobilization usually with the use of maxillomandibular arch bar fixation. In severely comminuted and contaminated war injuries the blood supply may be compromised, the additional trauma by open procedures may lead to devitalization of bone fragments (sequestration) and loss of bony substance (due to necessary stripping of Oral and Maxillofacial Surgery and Periodontology 94
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