Rehabilitation of Mid Facial Tissue Defects Due to Gun Shot Injury- A Case Report-Juniper publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY
Abstract
The extensive damage of the tissues of face and
oro-facial region possesses great challenge for the treating dental
surgeon to rehabilitate towards near perfect condition physiologically,
functionally and esthetically [1,2].
The initial analysis towards the extent of damage is
difficult to assess and later due to increase in chances of infection,
ischemia and necrosis there are reduced chances towards faster healing,
which complicates the reconstruction/rehabilitation part.
The rehabilitation of the defects usually involves
initial stabilization, definitive reconstruction and later secondary
reconstruction by surgical or prosthodontical techniques of restoring
the lost tissues/defects. The latest surgical protocol implies the
immediate surgical reconstruction as a method of choice [3-7].
This case report describes the rehabilitation of
Gunshot wound managed through surgical and prosthodontic principles with
gratifying results
Keywords: Gun Shot Wound; Reconstruction; Nasolabial Flap; Multidisciplinary approach; Rehabilitation
Introduction
The available literature on fire arm injuries is
voluminous, much of which is debatable or controversial at best. There
are many of myths which can be dispelled. Scientific study and practical
experience on the battlefield and in emergency rooms have documented
the important factors which include projectile type (i.e. jacketed
versus non jacketed), shape, victim proximity to muzzle (shot gun
injuries), body armor that may have been penetrated, and the specific
tissues encountered [8-12].
Unlike the abdomen, pelvis, or many extremity wounds, the maxillofacial
region consists of a highly osseous framework with a relatively thin
soft tissue drape. The influence of bone fragmentation and secondary
missiles is far more prevalent in this region and significantly impacts
wound healing and treatment. Numerous authors have proclaimed “treat the
wound, not the weapon” [13].
By following this rationale, appropriate surgical treatment principles
are adhered to and the wound is individually treated based on
presentation and mechanism, rather than an arbitrary adherence to an
unsubstantiated classification system. These injuries should be handled
in the manner like typical blunt trauma injury is treated: direct open
approaches to expose the fractures and debridement of injured soft
tissues are followed by reduction, rigid internal fixation, and primary
soft tissue closure. Similarly, in perforating injuries the projectile
exits the tissue and leaves an entrance and exit wound, which should be
managed as described for penetrating injuries. Avulsive wounds
demonstrate significant loss of soft or hard tissue and are the result
of high energy projectiles (high-velocity rifle or close-range shot
gun). Typically, these injuries require multiple operative interventions
and true craniofacial principles to reestablish vertical and horizontal
facial pillars and anterior projection. Because variable amounts of
tissue are lost, primary or secondary grafting is required to replace
soft and hard tissue bulk which are common, during rehabilitation of
such injuries.
Case Report
A 25 yrs old serving soldier reported to our center
with severe mid facial injury due to Gun shot. On examination he was
conscious, alert and oriented to time, place and person. His upper lip
was torn in to two (degloving injury of the upper lip),nasal aperture
shattered, dorsum was injured and his bridge of the nose was flattened (Figure 1).
On intra oral examination there was avulsion of Upper anteriors on the
right side and the left anteriors of the maxillary arch were fractured.
Initially after stabilization the patient was subjected to CT scan and
radiographs to rule out any injury to skull, brain and other bony
injuries. After confirming there was no bony injury, a multidisciplinary
approach was planned for comprehensive management. Patient was taken up
under general anesthesia with oral intubation. Initially debridement
was done and soft tissue closure was carried out in layers using 3-0
vicryl (Figure 2).
The lip and nasal deformities were successfully corrected using a
nasolabial flap. An inferiorly based nasolabial flap was designed. In
this case the distal end of the flap is thinned by defatting and the
distal part is folded and used as an inner lining. The inner layer
sutured from proximal to distal by absorbable suture (4-O Vicryl) and
the outer layer is sutured by (5-O Prolene). Care was taken to preserve
the intervening skin bridge representing the nasofacial aesthetic line.
To maintain the nasal patency and to retain the contour of the dorsum of
the nose and nostrils, soft tissue closure was carried out with nasal
stents placed inside the nostrils. Pressure dressing was placed and
checked postoperatively. Sutures are removed after 5-7 days
postoperatively. The right maxillary anteriors, tooth no 11, 12 and 13
which were fractured, avulsed and beyond restorable were extracted (Figure 3). The fractured teeth no 21 and 22 were root canal treated (Figure 4),
core build up was done and porcelain fused to metal crown was placed.
The missing teeth on the right maxillary arch which were extracted were
prosthetically restored by using removable acrylic partial denture (Figure 5).
There were multiple surgeries carried out by the Plastic surgery
department. The patient underwent successive surgeries to get the final
and better soft tissue shape and characteristic for both nostrils.
Follow up was done for a period of one year and there were no
post-operative or rehabilitative complications (Figure 6).
Discussion
Gun Shot wounds have been classified in to three
types based on the type of injury caused. They are penetrating,
perforating and avulsive [14].
In penetrating wound the projectile does not exit and remains within
the target and typically causes soft tissue laceration and possibly bony
fracture as all the kinetic energy is transferred to the victim. If the
projectile exits it is called as perforating wound. If the projectile
exits with substantial loss of tissues it is called as avulsive wound.
Recent literature suggests that velocity of impact has been
overemphasized and that the most appropriate classification scheme
involves either impact energy or the type of firearm involved [10].
Two main treatment protocols exist for these types of
wounds. An excellent protocol for management of avulsive injuries to
the maxillofacial region has been described by Clark and
colleagues,Robertson and Manson [15-17].
This protocol may be termed as the immediate bone and soft tissue
protocol. Briefly, the authors advocate that any high-energy or avulsive
injury of the maxillofacial region be approached with a systematic
algorithm as follows:
a) Initial debridement and excision of necrotic tissue followed by soft tissue closure and intravenous antibiotic therapy,
b) Repair of bone injury with traditional open reduction and fixation techniques used for blunt facial injuries,
c) Serial debridement every 24 to 48 hours, which
involves reopening the soft tissues in the area of avulsion and further
debriding interval necrotic tissue, hematoma, infection, and dead space,
followed by closure of the soft tissue wound, and
d) Definitive reconstruction with pedicled or free-tissue transfer to
Conservative debridement initially is performed to
minimize the amount of viable tissue that is excised on first look, yet
it ensures through serial debridement, so that all necrotic tissue is
eventually removed asit declares. By performing definitive
reconstruction early (within the first 2 weeks is recommended), the
surgeon is able to take advantage of the primary phase of wound healing
and can optimally avoid the detrimental effects of scars and wound
contracture that are nearly impossible to overcome. The disadvantage of
this protocol is that the surgeon must ensure that the wound bed is free
of infection and necrotic tissue before grafting, so that these factors
may compromise the graft.
As the projectile enters the victim, the
different layers of tissue react according to their specific properties.
Injuries to the dermis include abrasion, impaction of particulate
matter, and contusion. At closer ranges, burning and implanta-tion of
powder and residue may occur and may result in a tattoo. After the
projectile passes through the skin, it next encounters muscle tissue,
which is very elastic and may sustain defor-mation of as much as four
times the diameter of the projectile. On a cellular level, the muscle
along the pathway of the projectile becomes devitalized and necrotic. As
the projectile travels, it may also encounter other surrounding vital
structures such as nerves and blood vessels. The injuries to
neurovascular tissue are similar to injuries to muscle. Vessels may be
ruptured, crushed, or sheared, and spasm may occur. These injuries may
result in hemorrhage and in the formation of thrombi and hematoma. On a
cellular level, damage occurs to all three layers of the vessel wall [18].
Sensory and motor nerves may be damaged. When sensory
nerves stretch, anesthesia and paresthesia result; when motor nerves
stretch, conduction deficit, and loss of func-tion result. Injury to
bony tissue differs from injury to soft tissues. The minimal projectile
velocity required for bone fracture is 65m/s. Bone is very inelas-tic;
therefore, the type of injury that occurs depends on the type of bone
encountered by the projectile. Injury to cancellous bone usually results
in a defect of the drill-hole type. Injury to cortical bone or teeth
usually results in shattering. The resulting fragments may act as
secondary projectiles and may pose an aspiration risk [19].
The first procedure in definitive maxil-lofacial
management of a gunshot inju-ry is to irrigate the wound with normal
saline. Irrigation debrides any necrotic tissue, removes foreign bodies,
and brings the contaminants to nonpatho-genic concentrations. Simple
cutaneous wounds may be cleansed and dressed with bacitracin or
sulfadiazine cream 1%. Shattered bone and teeth along with debris should
be removed under copious irrigation. Injuries resulting in active
hemorrhage should be explored and repaired at the earliest. At the time
of hemorrhage control, obvious nerve damage should also be repaired.
Fractures should be treated with open reduction and internal fixation,
but such treatment may be a formidable task if there is gross
fragmentation. In such cases, closed reduction and intermaxillary
fixation is recommended, although not optimal but an acceptable
treatment.
Conclusion
Gunshot wounds should be managed by hemodynamic
resuscitation, airway management, and wound care. The step by step
treatment methodology will improve and have positive outcome of the
treatment. The patient was taken up for staged reconstruction using
multidisciplinary specialties of Oral and maxillofacial surgeon,
Prosthodontist and Plastic and reconstructive surgeon to successfully
rehabilitate has been illustrated in detail. Careful planning and
execution as per the treatment plan at the right time shall definitely
give the best results.
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