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Maxillofacial Injuries

Medical Science Publication No. 4, Volume 1

MAXILLOFACIAL INJURIES*

A Supplement to the Discussion of Specific Primary Considerations in Plastic Surgery,
presented by Colonel Bernard N. Soderberg

LIEUTENANT COLONEL JAMES E. CHIPPS, DC

This is a supplement to Colonel Soderberg's discussion to further emphasize the importance of early treatment of maxillofacial wounds. In the allotted time, only two points will be considered. First, the reduction of bone fractures and closure of soft tissue injuries as much as possible at the primary stage is of such benefit in the restoration of function and curtailment of later major reconstructive procedures that it is essential to proper maxillofacial surgery that such treatment be rendered. Second, too few patients have received this beneficial primary treatment in the past and the percentage can be improved upon in a future emergency.

Since Colonel Soderberg has adequately discussed the methods of primary treatment, only the results in a few cases need be shown in making the first point. Some of these wounds were treated in the first few hours in Korea before marked inflammatory reactions had occurred. Others were first treated in Japan after a necessary short delay for preparation of the infected wounds but before the response to injury had progressed to fibrosis.

Figure 1 illustrates a patient 14 days after sustaining severe stellate wounds of the right and left sides of the face with primary avulsion of the entire body of the mandible, the entire tongue, most of the suprahyoid structures and most of the hyoid. The wound was repaired within the first 6 hours in Korea. The scarring was minimal. The tissues were pliant. Muscle function was almost normal.

Figure 2 illustrates the early postoperative result of treatment for a severe avulsive wound of the middle face. The closure was complete. Face contour and muscle tone were maintained by treatment of the associated avulsive mandibular fractures. This treatment was also accomplished at a mobile surgical hospital in Korea.


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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FIGURE 1. Successful early closure after avulsion of mandible and tongue, fourteenth post-wound day.

FIGURE 2. Successful early closure of avulsive wound of middle face with loss of right body of mandible, twelfth post-wound day.


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Figure 3 shows a ROK soldier as received at an evacuation hospital. The wound appears to require extensive reconstructive surgery for repair and this most certainly would have been the case if early treatment had not been rendered. Actually, however, most of the tissues were not completely avulsed and could be returned to place and sutured. Figure 4 is the early postoperative result and figure 5 is the result in the sixth postoperative week.

Figure 6 illustrates a patient on the third post-wound day after evacuation to Japan. There was avulsion of the anterior and right body of the mandible and loss of considerable lip and chin tissue. Induration was marked. After 5 days preparation, the wound was closed over an acrylic dental splint which maintained the mandibular stumps in position and prevented undue distortion of the face following the closure. Figure 7 shows the postoperative result.

Figures 8 and 9 are the preoperative and postoperative illustrations of a severe middle-face wound closed in Japan. The early surgical

FIGURE 3. Middle-face injury, ROK soldier, first day of wound.


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FIGURE 4. Same patient as figure 3, second postoperative day.

closures in these cases greatly modified the eventual reconstructive program.

Figure 10 shows a minor loss of deep tissue with extensive loss of superficial tissue. A skin graft was applied as soon as possible. Figure 11 illustrates the early result. Although the eventual program of repair was not materially altered by this early treatment, the patient benefited markedly by maintenance of muscle function through prevention of undue fibrosis. In addition, there were such secondary benefits as early return to a normal diet, reduction of the need for prolonged dressings and nursing care, shortened period of chemotherapy and the like.

In all such cases, the psychological benefits from early treatment are as striking as the functional benefits and should be further discussed. However, in this limited presentation, the consideration of the benefits of early treatment is closed with the statement that all who were primarily engaged in maxillofacial work in the Korean war be-


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FIGURE 5. Same patient as figure 3, sixth postoperative week.

FIGURE 6. Unclosed wound, third day, with marked induration.


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FIGURE 7. Same patient as figure 6, ninth postoperative day after closure over an acrylic splint.

came convinced that the time to begin definitive repair of such wounds is during the first few hours. For practical purposes, this is at the mobile surgical hospital level.

In considering how a higher percentage of patients in a future emergency might receive beneficial primary treatment, a large series of inadequately treated maxillofacial casualties in the Korean war was reviewed and the patients divided into six groups.

Group I

This group includes all those whose treatment was faulty or inadequate so that no material benefit resulted from the early treatment. Not all primary closures of wounds were successful. Of the repaired wounds involving the mouth, the breakdown rate was sufficiently high to cause some observers to question the advisability of early wound closure. However, these breakdowns almost invariably could be attributed to the failure to fully apply the principles of good surgery-


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FIGURE 8. Unclosed wound of middle face, fifth day.

the principles that Colonel Soderberg has just discussed. A few points specially applicable to maxillofacial wound management are further presented here.

A. Conservatism in Débridement. Although stressed in all discussions of maxillofacial wounds, this point requires repetition with particular emphasis on conservatism in the management of bone fragments. Only rarely was soft tissue about a face wound observed to have been excised beyond the probable limits of devitalization, but mandibular fractures were frequently seen to have been stripped clean of small bone fragments. At a general hospital in Japan, there were many cases in which certain bone fragments, given little chance of survival, were deliberately retained because of their value in fracture management. Many such fragments survived (fig. 12) and the few sequestrations observed were not attended by particularly harmful sequelae.

B. Tube Feeding. In addition to maintaining a better nutritional balance in the presence of oral wounds, a diet based on tube feedings


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FIGURE 9. Same patient as figure 8, ninth postoperative day.

instead of diets by mouth as tolerated is of material local value in readying the wounds for closure and in shortening the postoperative healing periods. This is probably explained on a local basis of less salivation, better wound immobilization, absence of fermenting food debris in the wound, and better application and retention of compression bandages.

C. Partial Closure of Indurated Wounds. Most of these wounds requirement an operation for débridement. It was often found during this procedure that, although the wound might not be entirely closed because of inflammation or tissue loss, the tissue about minor oral penetrations or overlying exposed bone could be approximated without undue tension and would heal during the period of preparation of the entire wound for delayed closure. Thus a simple, superficial wound could be made of a complex one, speeding up the program of repair. For the patient in figure 10, the minor oral penetrations in the base of the wound were freshened, slightly undermined and lightly


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FIGURE 10. Unrepaired wound, fourth day, with considerable loss of superficial tissue but minor loss of deep tissue and minimal penetration into mouth and mandible.

FIGURE 11. Sixteenth post-wound day, same patient as Figure 10, after early skin graft.

closed. The wound was then treated as a one-surface superficial wound while being readied for skin graft and an early graft could be applied with increased hope of success. Similarly, adjacent soft tissue could


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FIGURE 12. Severely comminuted fracture with deliberate retention of questionably vital bone fragments.

often be sutured over exposed bone during débridement and, if counterdrainage was established, the chance for bone survival was materially increased.

D. Concomitant Treatment of Jaw Fractures. Figure 13 illustrates a patient with extensive repair of soft tissue but with no definitive treatment of the associated mandibular fracture. The resulting depressed chin and elevated rami are typical of this type of injury. The lip is flaccid and there is drooling. Displaced bone fragments and adjacent soft tissues are now fixed. The facial and masticatory muscles have lost tone, partly from anatomical displacement and partly from suppression of voluntary function because of the pain associated with bone fragment movement.

If the bone is not generally aligned and moderately immobilized at the time of the wound closure, it cannot be secondarily treated during the critical period of fragment mobility without endangering the surgical repair during manipulation. Thus, the fracture should receive treatment prior to the soft tissue repair and, if this is to be quickly accomplished in the field, it is essential that the method of fracture


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FIGURE 13. Soft tissue wound repaired without reduction of severely fractured mandible.

management be simple. One such method, adequate in most cases, is reviewed. Figure 14 illustrates a common type of missile fracture. Fragments are displaced from the main body of the bone and there are several fractures through the dental arch. A smooth rod about one-sixteenth inch in diameter, readily available in brass, steel or aluminum at ordnance repair shops, is cut and bent to approximately the shape of the dental arch. The ends of the rod are looped. The rod is then wired to the mandibular teeth beginning with the anterior fragment, and each fragment is slipped slightly along the rod to contact with adjacent fragments (fig. 15). The last tooth on each side is wired to the loops in the rod, anchoring the rod. The rod is then manually contoured until the result is a generally correct dental arch that will contact the maxillary teeth. Isolated fragments are incorporated into the reduction by passing circumferential wires over the occlusal surface of adjacent teeth, over the rod and about the fragments. Figure 16 shows immobilization completed by the application of intermaxil-


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FIGURE 14. Typical missile fracture of mandible with 1/16 inch metal rod adopted for reduction.

FIGURE 15. Metal rod wired to teeth. Isolated fragments incorporated by circumferential wire.

lary elastics between the wires holding the rod and wires applied in any of a variety of methods to the maxillary teeth. The small elastics may be cut from readily available latex surgical tubing. The number of elastics is reduced to two on each side during transportation, a


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FIGURE 16. Immobilizatin completed by intermaxillary elastics to maxillary interdental wires.

traction sufficient to maintain comfortable occlusion without constituting a danger of asphyxiation in the event of hemorrhage or emesis.

At general hospitals, time and facilities usually permit construction of a splinting device during preparation of the wound for closure and the splint illustrated in figure 17 can be substituted for the metal rod. This splint is constructed only against the lingual surface of the dental arch and retained by steel wires looped about the cervices of the teeth and passed through holes constructed in the splint at the interproximal embrasures. It is superior to most splints in ease of insertion and adequacy of reduction and immobilization. It may also serve as a support for the closure of an associated soft tissue wound. Figure 18 illustrates a splint that bridges a gap caused by the primary avulsion of bone substance and will support the soft tissue following wound closure.

Occasionally, instances of overtreatment of fractures in the early stages were observed. Complex fracture gear often interferes with the surgical closure and precludes use of the important compression bandage. The blood supply to bone fragments, already markedly diminished, may be further impaired by excessive manipulation or intraosseous procedures in open reduction technics. Complex reduction and immobilization procedures can usually be safely deferred until the soft tissue wound has healed if the bone fragments are generally aligned and moderately immobilized by a simple device.

Many maxillofacial wounds can be managed by a general surgeon alone and others can be managed by a rhinolaryngologist or an oral surgeon, but usually combined efforts are indicated if the maximum in sound treatment is to be rendered. A more universal practice of


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FIGURE 17. Acrylic splint constructed to lingual surface of dental arch and retained by interdental wires through holes in the splint.

this cooperation should result in a considerable reduction in the percentage of inadequacies of treatment. Dental officers were usually assigned to mobile surgical hospitals as Eighth Army policy but are not yet included in the official tables of organization. The inclusion of a dental officer should be made official and, whenever possible, the dentist should be a trained oral surgeon.

Group II

This group consists of patients whose wounds were severe and apparently so specialized in nature that, frequently, no early definitive treatment was attempted. Progress notes that accompanied such patients usually showed that the first receiving surgeons, after rendering essential life-saving and supportive care, had deliberately evacuated them without definitive treatment in the hope that they would shortly reach designated centers for specialized care. There were not enough such centers and evacuation was not sufficiently rapid to provide the indicated early treatment at the time that it could best be done.


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FIGURE 18. Acrylic splint, constructed to support the lower lip after closure and to immobilize mandibular stumps after avulsive fracture.

The best solution to this problem, if there were no limitations of personnel, would be to greatly expand the use of specialized teams at forward hospitals. A partial solution would be a more positive and publicized designation of rear area specialty centers but this also would require a positive program for priority evacuations. A third, and more practical, solution is to show all concerned personnel through educational programs that most of the essentials of early wound care such as débridement, closure of tissue over exposed bone with counterdrainage, fracture immobilization and adequate use of supporting bandage, need not await a specialist.

Group III

At the other extreme from those with severe injuries were those whose injuries were essentially superficial but so multiple as to require tedious, time-consuming procedures for repair. Frequently, such patients were not treated at forward installations because of the more apparent urgency for treatment of more seriously wounded patients. However, maxillofacial wounds, even when physically superficial, always have psychological and social implications that take them out of the category of insignificant injuries. Lacerations about


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the lips that might readily be treated by cleansing and simple suture become contractures that require evacuation and complex plastic surgery after a few days healing. Dirt and debris blown through the skin that might initially be removed by a thorough sponging with detergents become "blast tattoos" that have kept many patients hospitalized in plastic centers for months. Figures 19 and 20 illustrate the probable prevention of a "tattoo" by cleansing a wound at an evacuation hospital in Korea shortly after the wound was incurred.

In addition to increased education as to the desirability of early management of maxillofacial injuries, the solution in this group also requires that adequate personnel be available at the forward hospitals. It is suggested that this personnel might be obtained in time of need from division dental personnel. There are 18 dental officers in the infantry division and their primary duties are materially altered when the division is in actual combat. The interests of the division

FIGURE 19. Markedly dirty wound of face.


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FIGURE 20. Same as figure 19 after "tattoo" preventive cleanup and early repair.

might best be served if two or three of these dental officers were detached during periods of combat and assigned to the mobile surgical hospital in most direct support of that division. Even when they lack formal surgical training, such officers can be readily trained by the hospital's staff to be of material aid during periods of stress.

Group IV

This group consists of those with multiple wounds whose maxillofacial treatment was deferred primarily because of a more severe injury of head, chest, or the like. Occasionally, this deferment was actually dictated by the patient's physical condition but more often it was due to overspecialization of staffs or delays in routine consultatory procedures or the like. Again, increased education for the personnel concerned is the solution.


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Group V

This group consists of those who received no definitive treatment because advanced personnel did not understand that such treatment was expected from them. It would seem that this group could be eliminated merely by the publication of directives or other minimal attempts at education, but such attempts have been misunderstood in the past.

As an example, an administrative letter from a higher headquarters is quoted in part:

"Maxillofacial Injuries

    The principle that definitive treatment of patients with maxillofacial injuries should be provided as early as feasible is well established. A continuing problem exists in the delayed evacuation of these cases to specialized treatment centers. . . . Stations should evaluate cases promptly to determine that adequate treatment is within the capabilities of local personnel . . . . Evacuation actions should be expedited maximally."

This letter has been cited as being a directive against treatment except in specialty centers, an interpretation just the opposite from the letter's intent.

As a second example, an attempt was made in Japan to analyze the preventable causes of breakdown of repaired maxillofacial wounds and publicize this analysis in an effort to improve the results. Shortly, patients evacuated to Japan from a hospital which had previously accomplished excellent treatment began to arrive without definitive surgery. After inquiry, one of the surgeons concerned replied that he had heard the repairs were breaking down so he had stopped performing them. Again, this was an interpretation just the opposite from the one intended.

In late 1951, a brief course in oral surgery for dental officers from evacuation and mobile surgical hospitals was established at Tokyo Army Hospital. The result was an immediate improvement in the management of maxillofacial casualties, not because a great deal of oral surgery had been taught but because the officers attending the course were able to observe patients at both ends of the evacuation chain and learn specifically what was expected of them at forward hospitals.

Group VI

This last group consists of those who were evacuated without treatment because a critical military situation precluded any but emergency measures. Perhaps little can be done about this problem. However,


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as in group III, the temporary assignment of two or three division dental officers to mobile surgical hospitals while the division is in combat would provide the hospital with additional personnel at a critical time.

Conclusion

The final result of treatment in maxillofacial wounds esthetically, functionally and psychologically, is largely dependent on the nature and degree of definitive treatment accomplished in the first few hours after the injury. Compared to the past, there was marked improvement in the management of such injuries in the Korean war but still further improvement can be attained.

After analysis of a series of untreated maxillofacial patients, it is seen that education of Medical Department personnel as to the essentiality of early treatment is the chief solution to the problem. One desirable method of instruction can be based on a policy of assigning replacement specialty personnel to advanced hospitals only after short periods of observation at rear area specialty centers in the evacuation chain.

The problem of the shortage of personnel at forward hospitals during periods of heavy casualties can be partially answered insofar as maxillofacial casualties are concerned by the temporary assignment of dental officers to the hospitals from combat divisions.

Acknowledgments

The patients illustrated in figures 1 and 2 were treated at the 8063 MASH by Dr. James R. Broun, Pendleton, Oregon. Figures 3, 4, 5, 19, and 20 illustrate patients treated at the 121st Evacuation Hospital and the illustrations were furnished by Captain Bruno W. Kwapis, DC. Dr. Marvin Cullen, Tampa, Florida, and Dr. Robert G. Canham, Chicago, Illinois, were associated with the writer in the management of the other casualties at Tokyo Army Hospital. The acrylic splint described in the text was first designed by Lieutenant Colonel James B. Neil, DC.