Injury, Int. J.

Care Injured 45 (2014) 206–211

Contents lists available at SciVerse ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Management of comminuted but continuous mandible defects after gunshot

injuries
Majeed Rana a, Riaz Warraich b, Ashkan Rashad c,*, Constantin von See a, Kashif A. Channar b,
Madiha Rana a, Marcus Stoetzer a, Nils-Claudius Gellrich a
a
Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
b
Department of Oral and Maxillofacial Surgery, King Edward Medical University, Lahore, Pakistan
c
Department of Oral and Maxillofacial Surgery, Bremerhaven Hospital (Reinkenheide), Bremerhaven, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Firearm injuries continue as a major public health problem, contributing significant
Accepted 22 September 2012 morbidity, mortality, and expense to our society. There are four main steps in the management of
patients with gunshot wounds to the face: securing an airway, controlling haemorrhage, identifying
Keywords: other injuries and definitive repair of the traumatic facial deformities. The objective of this study was to
Gunshot injuries determine late outcome of two treatment options by open reduction and internal fixation versus closed
Maxillomandibular fixation reduction and maxillomandibular fixation (MMF) in the treatment of gunshot injuries of the mandible.
Open reduction
Methods: Sixty patients of gunshot injury were randomly allocated in two groups. In group A, 30 patients
Closed reduction
Internal fixation
were treated by open reduction and internal fixation and in group B, 30 patients were treated by closed
reduction and maxillomandibular fixation. Patients were discharged as the treatment completed and
recalled for follow up. Up to 3 months after injury, fortnightly complications like infection, malocclusion,
malunion of fractured fragments, facial asymmetry, sequestration of bone and exposed plates were
evaluated and the differences between two groups were assessed. The follow-up period ranged from 3
months to 10 months.
Results: Patients treated by open reduction tended to have less complications as compared to closed
reduction.
Conclusion: Based on this study open reduction and internal fixation is the best available method for the
treatment of gunshot mandible fractures without continuity defect.
ß 2012 Elsevier Ltd. All rights reserved.

Introduction Surgical management of facial gunshot wounds is generally

Since last decade the incidence of violent crimes are on rise in
Pakistan society. Gunshot injuries in particular have become
increasingly more frequent in the civilian population.1–3 Due to the
instability and increase in violence in our region, the number of
deaths has also increased mainly due to firearm weapons.4,5 Main
causes of the gunshot injuries in this part of the world are violent
crimes, domestic violence, accidental discharge of bullet, suicidal
attempts and air shooting.4,5
* Corresponding author at: Department of Oral and Maxillofacial Surgery,
Postbrookstr. 103, 27574 Bremerhaven, Germany. Tel.: +49 0471 299 2816;
fax: +49 0471 299 3318.
E-mail addresses: rana.majeed@mh-hannover.de (M. Rana),
drriazwarraich@hotmail.com (R. Warraich), dr.arashad@yahoo.com (A. Rashad),
constantinvonsee@gmx.de (C. von See), kashifchannar@kemu.edu.pk
(K.A. Channar), massadiq@hsu-hh.de (M. Rana), stoetzer.marcus@mh-hannover.de
(M. Stoetzer), gellrich.nils-claudius@mh-hannover.de (N.-C. Gellrich).
divided into 3 stages debridement, fracture stabilisation, and
primary closure; reconstruction of hard tissues, provided soft tissue
coverage is adequate; and rehabilitation of the oral vestibule,
alveolar ridge, and secondary correction of residual deformities.6,7
Comminuted fractures of the mandible as a result of gunshot injuries
have been treated by a number of methods, including closed
reduction, external pin fixation, internal wire fixation and more
recently, open reduction and internal stable fixation using plates
and/or screws.7 Before the development of reliable implants and
instrumentation for rigid fixation, most comminuted mandibular
fractures as a result of gunshot injuries were treated by closed
reduction. This was done to avoid periosteal stripping and
devascularisation of comminuted bony segments. Closed techniques
were preferred because of poor treatment outcomes with open
reduction that primarily involved internal wire fixation. These cases
frequently developed infection and nonunion. In particular,
conservative methods for the treatment of gunshot wound fractures
have been recommended by many authors to avoid periosteal
stripping of small, partially devitalised segments.8–10

0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2012.09.021
 M. Rana et al. / Injury, Int. J. Care Injured 45 (2014) 206–211
Recently, open reduction and stable internal fixation using
plates and/or screws has been advocated for comminuted
fractures. Li and Li11 also recommended open reduction and
internal fixation (reconstruction plate) treatment modality with
adjunct maxillomandibular fixation (MMF) for multiple site
comminuted mandible fractures. On the other hand, open
reduction and internal fixation of comminuted fractures goes
against the most basic of maxillofacial surgery dogma that states
comminuted fractures should be treated closed to prevent
stripping the blood supply from the fragments.12
In the management of gunshot wounds in open and closed
reduction the opinions are divided. This study was designed to
compare the above-mentioned two techniques, which have better
clinical result and fewer complications, consequently contributing
towards the goals of a better treatment option and in due process
providing benefit the concerned patients.
Hence this study was conducted to determine late outcome of
two treatment options by open reduction and internal fixation
(ORIF) versus closed reduction and maxillomandibular fixation in
treatment of gunshot injuries of the mandible.
Materials and methods
The study was approved by the local ethics committee at the
King Edward Medical University Lahore (F-07-2932). Trial was
approved and registered at the research, training and monitoring
cell, College of Physicians & Surgeons, Pakistan. RTMC allotted
registered number: DSG-2006-066-380. Written informed consent
was obtained from each patient.
A total number of 70 patients reported during the study period
from November 2008 to November 2009 were treated for the same.
Out of these, 4 patients were associated with continuity defect
greater than 1 cm and 2 were associated with mid face fractures,
one patient had multiple gunshot injuries to mandible and soft
tissue deficient cover and three patients lost their follow up thus
were excluded from the sample. Hence 60 cases with single
gunshot injury to the mandible, continuity defect less than 1 cm
and no intra-oral communication or/educate soft tissue cover
available intra-orally and extra-orally for primary closure were
included in this study. Mandible sites affected were as followed: 28
body (47%), 18 symphysis/parasymphysis (30%), and 14 angle
(23%). The degree of comminution was assessed by the number of
fragments with an inclusion criteria of at least 1 cm in diameter.
Eight patients had a single free bone fragment, 15 had 2, 11 had 3,
and 26 had at least 4 fractured fragments. In 43 cases at least 1
tooth was within the comminuted site, whereas the tooth/teeth
was/were removed in 28 cases. Regarding the ORIF group, 14
patients were treated with a large mandibular reconstruction plate
and 16 with at least 1 miniplate.
Randomisation was done using a computer based software
‘‘EpiCalc2000’’. The software was used to generate serial numbers
1–70 into two groups randomly and those patients who fulfilled
the inclusion criteria were allocated serial numbers according to
date and sequence of admission to hospital. By placing the
allocations in sealed envelopes at the emergency ward, any entry
bias by the authors was prevented. The person responsible for
conducting the measurements at the time of assessment of
variables was blindfolded regarding the type of procedure that was
conducted.
All infected cases of gunshot injuries to mandible and case
presentation in hospital after three days of injury and displaced
fractures were excluded. The authors postulated untreated
mandible defects as being infectious after 3rd day of gunshot
injury. The timing of surgery varied considerably, ranging from the
same day as the injury up to 12 days after injury. 41 out of 60
patients were treated within 48 h post injury. Diagnosis was made
207
clinically and radiographically. Radiograph used for confirmation
and extent of fracture was orthopantomogram (OPG) and postero-
anterior (PA) view of mandible. Written Informed consents were
obtained from all patients or their parents/attendants, for inclusion
in either surgical procedure or for using their data in this research
study. The demographic information like name, age, sex and
address were recorded. There were 30 patients (group A) treated
by open reduction and internal fixation by reconstruction plates
and/or miniplates and in 30 patients (group B) were treated by
closed reduction and maxillomandibular fixation. Before interven-
tion, patient’s record was documented on the proforma. Blood
analysis was carried out at arriving to hospital site revealed
positive blood alcohol levels for 6 patients. Twenty-six out of 60
patients were smokers, whereof at least 7 patients out of ORIF
group did smoke postoperatively during hospitalisation. Six
patients reported of mandible fractures in their history: 3 of the
fractures occurred after vehicle accident, 2 after gunshot injury and
1 because of sports activity. For 2 of them the same mandible site
was affected.
The time needed for treatment (open and closed reduction) was
recorded. Furthermore postoperative pain analysis was conducted
with the help of a 10-point visual analogue scale (VAS) on a base
from 1st, 2nd and 5th day after treatment, where the patients
should rate their pain on a score from 0 to 10, with 0 describing a
situation without pain and 10 denoting a maximum intensity of
pain. Every patient received the same postoperative analgesic drug
therapy included 1000 mg Paracetamol (Perfalgan1) intravenous-
ly for 2 times per day for 3 days; per os: 600 mg Ibuprofen (Ibu-
ratiopharm1) (1st day: Ibuprofen 600 mg 3 times per day, 2nd day:
Ibuprofen 600 mg 2 times per day, 3rd day: Ibuprofen 600 mg 1
time per day, 4th day: Ibuprofen 600 mg 1 time per day) Antibiotic
prophylaxis consisted of 600 mg Clindamycin (Clindamycin-
Actavis1) intravenously for 3 times per day.
Patients were discharged as the treatment completed and
recalled for follow up. Up to 3 months after injury, fortnightly
complications like infection, malocclusion, malunion of fractured
fragments, facial asymmetry, sequestration of bone and exposed
plates were evaluated and the difference between two groups was
assessed. Proportions of facial asymmetry were assessed frontally
by indicating facial midline as a line perpendicular to midpupillary
line through the neck of crista galli. The follow-up period ranged
from 3 months to 10 months. The existence of facial asymmetry
was checked 3 months after injury.
Since the observed variables are largely dichotomous, chi-
squared tests were used to detect significant differences between
group A and group B. To check for statistical significance of
quantitative variables the Student t-test was used. A p-value less
than 0.05 was considered to be statistically significant. The
statistical analysis was conducted using SPSS for Windows version
16.0 (SPSS Inc., Chicago, IL, USA).
Results
The mean age of the patients in the study was 27.4 years (SD
10.7). The most common age group was 16–30 years followed by
31–45 years. The children under 15 years and elderly age group
45–60 years showed the least involvement with gunshot injuries of
the mandible (Table 1). Male female ratio was 7.5:1 (Table 2).
The timing of treatment of the patients varied considerably,
ranging from the same day as the injury up to 15 days after the
injury, with a mean duration of 5.8 days (SD 3.2) (Table 3).
The mean operative time needed was 86.4 min (SD 27.6) for
ORIF group, and 32.4 min (SD 12.2) for closed reduction group
(p < 0.05) (Table 4). Regarding postoperative pain analysis, in
contrast to 5th day evaluation, at 1st and 2nd postoperative day a
significant reduced pain score was obtained by treatment with
208 M. Rana et al. / Injury, Int. J. Care Injured 45 (2014) 206–211

Table 1 (3.3). Group B showed following complications: 7 facial asymme-

Distribution by age of patients with gunshot injuries to the mandible (n = 60).
try (23.3), 6 malunion of fractured fragments (20), 1 malocclusion
Age years Number of patients Percentage (3.3), 1 sequestration of bone (3.3), none infection (0) and none
ORIF Closed reduction ORIF Closed reduction exposed plates (0). Differences for both groups were not
group group group group statistically significant (p > 0.05) (Fig. 5). Twelve body fractures
15 3 2 10 7
(46%) resulted in complication: 4 malocclusions, 1 infection, 2
16–30 17 19 57 63 sequestration of bone and 5 malunion of fragments. Remaining 6
31–45 7 8 23 27 complications were located at symphysis/parasymphysis site
46–60 3 1 10 3 (33%): 1 infection, 1 sequestration of bone, 2 exposed plates and
Total 30 30 100 100 2 malunion of fragments.

Discussion

Table 2 Gunshot wounds to the maxillofacial region are not uncommon

Distribution by sex of patients with gunshot injuries to the mandible (n = 60).
in Pakistan. Despite this there is relatively little literature
Sex Number of patients Percentage discussing treatment and outcome of these injuries.
ORIF Closed reduction ORIF Closed reduction The predominant age group in this study was 16–30 years. 2nd
group group group group and 3rd decade constituted the major group in this study, which is
the same as mentioned in previous studies by Ellis et al.,7 Hussain
Male 28 25 93 83
Female 2 5 7 17 et al.,13 Hollier et al.,14 Finn,15 Newlands et al.,16 and Hussain
et al.17
Total 30 30 100 100
In this study the majority of patients presenting with gunshot
injuries to mandible were males and a considerably lower
proportion of patients were females. The male to female ratio
Table 3 was 7.5:1. This ratio matches with the conclusions of other
Duration of gunshot injury to treatment (n = 60).
researchers like Ellis et al.,7 Hussain et al.,13 Hollier et al.,14 Finn,15
Time duration Number of patients Newlands et al.,16 and Hussain et al.17 There is a general increased
ORIF group Closed reduction predilection for males to be victims of firearm injuries throughout
group the country.
1st day 1 2
We found MMF method less time consuming, technically easier
2nd day to 5th day 16 13 to perform with lower incidence of postoperative pain. Less
6th day to 12th day 12 13 postoperative care and short hospitalisation period reduce the cost
>12 days 1 2 of treatment.
The use of rigid internal fixation for the treatment of
maxillofacial trauma has become very popular during twentieth
Table 4 century. Large and small bone plating systems have been
Mean operative time needed for injury treatment (min). Data in brackets constitute
developed for the treatment of mandibular fractures, and both
standard deviation (SD).
have their advocates. At that time many authors have recom-
ORIF group Closed reduction group mended open reduction of comminuted mandibular fractures
86.4 (27.6) 32.4 (12.2) using nowadays out of fashion K-wires as an internal splint, or
removing the comminuted segments, crushing them and replacing
them as a free graft.18 Dingman and Natvig19 described in their text
on facial fracture surgery ORIF method of comminuted mandibular
Table 5 fractures using intraosseous wires or bone plates. A series of 32
Mean postoperative pain analysis with the help of a 10-point visual analogue scale
low-velocity gunshot wounds to the mandible were reported by
(VAS). Data in brackets constitute standard deviation (SD).
Neupert and Boyd.20 Although they stated a preference for
Postoperative ORIF group Closed reduction group p-Values conservative management, 19 of 32 cases required open reduction
1st day 6.9 (1.2) 5.5 (1.2) 0.0045 with wire fixation or external pin fixation. They reported an
2nd day 7.4 (1.5) 5.3 (1.4) 0.0018 infection rate of 27% with this treatment, whereas 18% developed
5th day 2.6 (0.8) 2.4 (0.8) 0.078 continuity defects that required subsequent bone grafting. They
attributed approximately half of the continuity defects to overly
aggressive debridement and recommended conservative debride-
closed reduction and MMF compared to treatment with ORIF (1st ment of devitalised bone and teeth.
day: ORIF: 6.9 (SD 1.2), closed reduction: 5.5 (SD 1.2); 2nd day: Effective use of ORIF using the ASIF (Association for the Study of
ORIF: 7.4 (SD 1.5), closed reduction: 5.3 (SD 1.4); both significant) Internal Fixation) approach with large mandibular reconstruction
(Table 5). plates has been reported by some investigators and that infection
Figs. 1–4 illustrate a case out of open reduction group with was caused mainly by loosing of hardware.21,22 In our follow up
preoperative clinical and X-ray view, as well as intraoprative and findings infection occurred in none of total patients treated via
postoperative documentation. MMF and 6.6% occurred in total of the patients treated with ORIF.
A total of 26 out of 60 patients encountered complications. With This nearly corresponds with the findings of Dingman and Natvig
58% of these complications occurring in group B and 42% in group and others, who found infection rate around 13% with open
A, the complication rate was higher in closed reduction and MMF reduction and internal fixation.19–21 Newlands et al. reported the
group (A: 11; B: 15). For group A complications were in descending complication in closed reduction in 10% of cases.16 However, our
order (percentage values in bracket): 3 malocclusion (10), 2 results are in contrast with the results of Neupert and Boyd,20 as
infection (6.6), 2 sequestration of bone (6.6), 2 exposed plates (6.6), they reported an infection rate of 27% with ORIF treatment, which
1 malunion of fractured fragments (3.3) and 1 facial asymmetry is a high rate.20 While in our study both infection cases were not
 M. Rana et al. / Injury, Int. J. Care Injured 45 (2014) 206–211
Fig. 1. Extraoral (left) and intraoral (right) view after injury.
Fig. 2. OPG showing comminuted mandibular body fracture.
Fig. 3. Reconstruction plate applied to the mandible.
correlated to substance abuse, at least 7 patients all out of ORIF
group did smoke postoperatively during hospitalisation, whereas
none of the patients had alcohol intake. But these findings have to
be treated with caution since they are based on self-reporting. It
has to be assumed that especially for alcohol abuse subjective
report can be influenced by the fact that Pakistan is a
predominantly Muslim country where alcohol intake is prohibited.
Serena-Gómez and Passeri23 concluded a close correlation
between substance abuse and postsurgical complication in
patients with mandibular fractures, with infections representing
the predominant complication.
209
Our results showed that 3 malocclusions were in patients
treated with ORIF. Although it appeared that open reduction and
stable internal fixation caused more malocclusions than the closed
reduction group, related to the number of fractures treated, only
10% of patients treated with open reduction and internal fixation
developed malocclusion. There was no statistically significant
relationship between the development of malocclusion and either
the type of treatment rendered in our study. In a study with 30
patients treated with osteosynthesis, Okoturu et al.24 reported of
malocclusion as the most frequent complication with 23.3%. This is
in accordance with the findings in our study, even so we noticed
lower malocclusion rate (10%). Furthermore our results are
comparable with other studies as by Ellis et al.7 and Smith and
Johnson,22 who reported 4.1% malocclusion in their retrospective
study. All cases were of ORIF group. In another study Baurmash12
reported no occlusal complication in closed reduction.
The adaptation of the reconstruction plate requires skill and
time, and the contour is not always perfect. This may be the reason
of exposed plate. Infection at the site and the significant soft tissue
cover is also an important factor. In this study two patients
developed this complication, which cannot be compared with
closed reduction group. In a retrospective study by Ellis et al.7
stated that exposed plate is a rare complication encountered
because of inadequate adaptation of reconstruction plates. New-
lands et al.16 reported that this complication occur because of
infection at hardware site, or loose reconstruction plates.
Much of the past literature concerning ORIF of comminuted
mandible fractures cited devascularisation of the comminuted
segments as the reason for the selection of closed treatment. The
sequelae of devascularisation were said to be bony sequestra,
infection, and nonunion.
Two patients of ORIF developed sequestration in this study. This
was removed surgically. Post surgical infection was the reason of
sequestra and inability to cover wound primarily. Usually not
undersized, worth preserving individual fragments were incorpo-
rated into the plates after smoothening of bony edges. Our results
for the sequestration of devitalised bone are not in the favour of
Newlands et al.16 He found only a single case of sequestration in
closed reduction with MMF group. We can assume that
sequestration is an independent complication and can occur in
both groups. Important is if soft tissue is deficient. If so,
reconstruction of soft tissue must be planned.
The most frequent complication was malunion developed in 7
cases out of the total sixty cases. Six patients (20%) were of closed
reduction and MMF group and one patient (3.3%) with open
reduction. Out of 6 patients, three developed non-union, of whom
2 required bone grafting to effect osseous union. The other patient
was initially treated closed for an angle fracture and had
postoperative rotation of the ramus. The patient was then planned
for open reduction and reconstruction bone plate fixation. There
210 M. Rana et al. / Injury, Int. J. Care Injured 45 (2014) 206–211
Fig. 4. Postoperative early (6th day post-op; left) and late (22nd day post-op; right) outcome.
was good bone contact so no bone graft was necessary, and the
patient healed uneventfully. Three patients developed malunion.
Osteotomy was done to recontour the continuity. The cause was
inability to obtain intimate bony contact of all the fragments by
closed reduction so that some were never accurately reduced.
Malunion and non-union was common in closed reduction group.
This study favours the results of other authors as they suggested
that malunion is common in closed reduction with MMF or
external pin fixation than ORIF.7,12
We observed that the incidence of postoperative facial
asymmetry was higher in the closed reduction group (23.3%) than
ORIF (3.3%). A study by Finn,15 established that closed reduction
was followed by a higher incidence of postoperative facial
deformity than were open reduction and fixation. While malunion
of fragments and facial asymmetry seemed to be associated with
treatment modality, malocclusions and exposed plates were site-
dependant. This might be due to the fact that in closed reduction
and MMF group bony fragments could not be repositioned under
visual control. Furthermore occlusion is centred at molar and
mandible body site. Exposed plates can be the result of particularly
little soft tissue coverage with lower lip movement at symphysis/
parasymphysis site.
Although with a sample of 60 patients and a follow-up period of
3–10 months it is not enough to draw any statistically significant
Fig. 5. Late complications outcome for open reduction and internal fixation and
closed reduction and maxillomandibular fixation.
conclusion in search for an ideal treatment. It may however be
deduced that ORIF is a better treatment option amongst the two
procedures in the management of gunshot injuries to the
mandible.
Conclusion
Rigid internal fixation is best available method for the
treatment of gunshot mandible fractures without continuity
defect being superior to more conventional techniques in spite
of minor infection rates. The infection can, however, be reduced by
careful selection of patients, meticulous debridement, use of
antibiotics, skill and experience of the surgeon. The results show
that majority of the patients were young adult males. It was also
seen that open reduction and internal fixation was advantageous
as it allowed immediate or early mandibular mobility, with good
functional and aesthetic results and a tendency towards a lower
rate of late complications.
Conflict of interest statement
The authors declare that they have no competing interests.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.injury.2012.09.021.
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