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British Journal of Oral and Maxillofacial Surgery 58 (2020) 324–328

Clinical use of internal distraction osteogenesis in the

rehabilitation of gunshot injuries of the mandible
X.-g. Niu ∗ , Y.-b. Du 1 , K. Ji 2
Department of Stomatology, First Outpatient Department, Logistics Support Department of Central Military Commission, Beijing 100842, PR China

Available online 23 January 2020

Abstract

Rehabilitation of gunshot injuries that require combined reconstruction of bone and soft tissue poses a considerable challenge. We describe
three cases of rehabilitation for mandibular defects and deformities caused by gunshot injuries. After debridement, three kinds of internal
distractors were used. The bony transport discs were distracted about 10-22 mm, and the new bone formed well in the distracted gaps. There
was no evidence of infection during the consolidation period or follow up. Aesthetic appearance was also pleasing after treatment. Internal
distraction osteogenesis after debridement might be a practical way of synchronously reconstructing bony and soft tissue after mandibular
gunshot injuries.
© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Distraction osteogenesis; Mandibular defects; Gunshot injury

Introduction shot injuries treated by initial wound debridement followed

by internal distraction osteogenesis.
Facial gunshot injuries result in devastating functional and
aesthetic consequences for patients, and may eventually lead
to mental and psychological disorders. The task of treating
maxillofacial gunshot wounds is extremely challenging and Patients and methods
complex, as it not only involves functional recovery includ-
ing mastication, feeding, and articulation, but also takes into Patients were informed in detail about the treatment plan, and
account the aesthetic effects by restoration of the original their consent was obtained. The study had the approval of the
appearance as far as possible.1 Consequently the treatment, institutional ethics committee.
repair, and reconstruction of facial gunshot injuries remain
an urgent task for an operating surgeon. Here we describe
the successful management of three patients who had gun-
Case reports

Case 1

∗ Corresponding author at: Department of Stomatology, First Outpatient
Department, Logistics Support Department of Central Military, Commission
22 Fu Xing Road, Beijing, 100842, PR China Tel.:+86 139 11529649.
E-mail addresses: niuxuegang1973@163.com (X.-g. Niu),
dyb1964@126.com (Y.-b. Du), jikaikq@126.com (K. Ji).
1 Tel.: +86 135 11076876.
2 Tel.: +86 15701125975.
https://doi.org/10.1016/j.bjoms.2019.12.012
0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A 22-year-old man was hit in the region of the mandibular
symphysis by pellets from a gun. He was fully conscious,
and his vital signs were within normal limits. The fracture
site was exposed under general anaesthesia, and rinsed thor-
oughly with hydrogen peroxide and normal saline. After
careful exploration, fragments of the pellets were removed.
 X.-g. Niu et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 324–328 325

The alveolar crest had exploded in multiple fragments and the

tissues were macerated and mixed with fragments of teeth.
The lacerated alveolar crest (with the corresponding teeth
from the lower right first premolar to the left central incisor)
was removed, and the fractured mandible reset with the help
of dental arch splints. The osteotomy line was then marked
on the residual bone with an oscillating saw and osteotome
to produce a 20 mm × 10 mm transport disc, and the internal
linear distractor was installed vertically. The fracture of the
mandibular symphysis was stabilised by the fixation plates
of the distractor at the same time (Fig. 1A). After irrigation
with normal saline the wound was closed and the distraction
activator passed percutaneously under the chin. Postopera-
tively, the patient was treated with antibiotics for a week. The
wounds were cleaned with hydrogen peroxide and normal
saline twice daily.
After a latency period of a week, the distraction was
started at 1 mm/day (0.5 mm twice a day). However, on
the third day the mucosa broke down, and with the dis-
tractor exposed during distraction the treatment had to be
suspended. The broken mucosa had to be released, and a
week later the distraction restarted for 10 consecutive days
at a rate of 0.7 mm/day. At the end of distraction, the disc
was raised about 10 mm with a radiolucent distraction gap.
After months of consolidation, the 3-dimensional computed
tomographic image (CT) showed that the new bone had
formed well in the distraction gap (Fig. 1B), and the height
of the reconstructed alveolar ridge was satisfactory. The
patient then had a further operation to remove the distractor
(Fig.1C).

Case 2

A 31-year-old woman had had a right mandibular defect

caused by a gunshot injury treated by us. During the ini-
tial debridement, the loose and damaged teeth and non-vital
soft tissue were cleared. The mandibular fracture was then
stabilised with titanium plates.
A year later necrotic bone had formed in the upper two-
thirds of the right mandibular body (Fig. 2A), so a second
debridement and reconstruction were required. The necrotic
bone was debrided, which resulted in a 17 mm × 12 mm Fig. 1. (A). The internal distractor was installed vertically and the fracture
defect with only a 10 mm mandibular lower edge left. The stabilised by the fixation plates of the distractor at the same time. (B). The
bony transport disc was then constructed in the mandibu- 3- dimensional computed tomographic view shows that the newly-formed
bone was evident in the distraction gap after three months of consolidation.
lar symphysis, and a internal curvilinear distractor inserted (C). The oral view shows that the height of the reconstructed alveolar ridge
(Fig. 2B). After a week, distraction was started at a rate of had healed after three months’ consolidation.
1.05 mm/day for 16 consecutive days. The bony transport
disc was then distracted around an arc of about 15 mm with Case 3
a radiolucent distraction gap (Fig. 2C).
After three months of consolidation, the newly-formed The patient was a 19-year-old man who was shot in the max-
bone was radiologically evident in the distraction gap. A year illa and right mandible from a short distance by a hand-made
later the alveolar crest was rebuilt, and the density of the gun. This caused considerable occlusal derangement and
distracted gap was almost the same as that of the neighbouring deviation of the jaw with loss of the condyle and decortication
bones (Fig. 2D). of the ramus in the right side.
326 X.-g. Niu et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 324–328

Fig. 2. (A). The radiograph shows the necrotic bone formed in the upper two-thirds of the right mandibular body. (B). After debridement of the necrotic bone
the transport disc was constructed in the remaining bone, and the internal curvilinear distractor was firmly fixed. (C). At the end of distraction, the bony transport
disc was distracted around an arc of approximately 15 mm, with a radiolucent distraction gap. (D). A year after distraction the density of the distracted gap was
almost the same as that of the neighbouring bones.
 X.-g. Niu et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 324–328 327

Three months after the initial operation the repair and

reconstruction were completed through a submandibular inci-
sion under general anaesthesia. During the first procedure the
reverse “L” osteotomy was made in the basal part of the resid-
ual condyle to produce a 15 mm × 10 mm transport disc, and
an internal linear distractor was fixed in a forwards and down-
wards direction. After a latency period of seven days, the
transport disc was moved 1 mm/day (0.5 mm twice a day) for
10 consecutive days. Three months later the second procedure
was done to remove the distractor. We found that the ramus
had lengthened about 10 mm forwards and downwards, and
the new bone had formed well in the distraction gap. We then
made the transverse osteotomy on the inferior part of the
ramus and another distractor was fixed in the direction on the
long axis of the ramus. After 7 days’ latency, the distraction
was activated at 1 mm/day for 12 consecutive days.
Three months later, the third operation was done to remove
the distractor and it was found that the ramus had lengthened
about 12 mm vertically, and new bone had formed well in the
distraction gap. We then did a Le Fort I osteotomy to move the
maxilla forwards, and the rectangular osteotomy was made in
the mental region to adjust the occlusion. The right mandibu-
lar body was obviously extended, and the facial appearance
and the occlusion were also improved. The 3-dimensional
CT showed obvious extension of the right mandible and the
well-reconstructed new bone (Figs. 3A and 3B).

Discussion

Gunshot wounds to the face present serious challenges to oral

and maxillofacial surgeons. In contrast to blunt facial trauma,
these injuries result in appreciable loss of bone and soft tissue,
and the severity is not always apparent on initial presentation.
Reconstruction of these defects is often complicated by tissue
ischaemia, necrosis, and infection.2
The severity of the injury depends on the calibre of the
weapon used and the distance from which the patient has been
shot. Early and appropriate surgical management has proved
to be influential on the final outcome and aesthetic result.
Treatment of these wounds should be planned and carried out
carefully to avoid aesthetic complications. It sometimes takes
multiple-staged corrections to achieve the targeted functional
and aesthetic treatment plan. Prevention and control of infec-
tion is one of the most important goals to achieve the success
of the treatment.3
Low-velocity injuries cause limited damage along the mis-
sile path, result in little loss of bone and soft tissue, and are
generally treated similarly to blunt facial trauma, with limited
debridement, immediate bony reconstruction, and primary
closure of soft tissue.4
High-velocity weapons, including rifles and close-range
shotguns, inflict considerably more damage. In addition to the
initial cavity created by the bullet’s path, there is an evolving
pattern of tissue loss, with resulting loss of bone and soft
tissue for several days or weeks.5 Traditional treatment of
Fig. 3. (A). The 3-dimensional computed tomographic view of the miss-
ing and shortened mandibular ramus caused by gunshot injury. (B). The
3-dimensional computed tomographic view of the mandibular ramus that
had been reconstructed by internal distraction osteogenesis.
these injuries involves initial wound debridement and closure
of soft tissue without replacement of lost bone.6
In the emergency treatment of our cases, the shattered
bone and teeth, together with debris, were removed under
copious irrigation with great care to preserve the worthwhile
periosteum, which might have an important role in the regen-
eration of bone. In Case 1, following the initial debridement,
immediate internal distraction was used to reconstruct the
lost alveolar ridge in the region of the mandibular symph-
ysis. The complete osteotomy was made with an oscillating
saw under a water spray, and the professional osteotome was
used to protect the periosteum as much as possible. The dis-
tractor was then fixed with several bilateral cortical screws
to ensure the excellent stability that is important for the bone
328 X.-g. Niu et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 324–328
to regenerate. Unfortunately, the perforation of the covering
mucosa during the distraction delayed the treatment.
For low-velocity injuries, morbidity can be reduced by
early and comprehensive management of soft tissue during
the first stage with less aggressive debridement. A primary
closure or local flaps are preferred over secondary healing,
which may cause excessive scarring. Fractured bones should
be aligned if attached to muscle and periosteum, and the plate
should be fixed according to principles of rigid fixation.7
In our opinion immediate distraction osteogenesis might be
considered, provided soft tissue is adequate to achieve water-
tight closure without tension. To avoid mucosal tearing, the
distraction time should be delayed and the speed reduced.
However, in the case of high-velocity injuries, the condi-
tions of soft tissues for immediate distraction osteogenesis
are poor. It was hard to close the wound without tension,
and multistage treatment might be a better option. So, to
ensure success, we would rather delay distraction than do
it immediately, as in the two more severe cases.
The distraction device is indispensable for the technique,
and a lot of work has been done on its design and fabrication.
In the early stage, the devices were unidirectional, but these
were no good for complex distraction. In recent years, some
multiplanar and curvilinear distractors have been developed,
but only a few of them are internal devices that can be buried
or semiburied.8,9 The curvature of the internal curvilinear
distractor we used in Case 2 was suitable for the region of the
mandibular symphysis. The transport disc that consisted of
the central and lateral incisors was distracted around an arc
to the molar region to rebuild the lost alveolar ridge.
In Case 3, we did a two-stage internal osteogenesis dis-
traction. First, the right mandibular ramus was extended
forwards and downwards to correct the right-hand twist of
the mandibular symphysis. In the second stage, the vector of
the distraction was adjusted in the direction of the long axis
of the right mandibular ramus to lengthen it vertically.
In all our cases we used internal distractors instead of
external ones10,11 to improve stability, avoid distracting scars,
and achieve optimal compliance. They all worked well, and
there was no evidence of infection during the consolidation
period or follow up. The aesthetics were also pleasing.
Distraction has many advantages in mandibular recon-
struction, as it avoids bone grafting procedures and their
associated complications. It has also the advantage of recre-
ation of soft tissues as well as hard tissues.12,13 However,
it is used more for reconstruction after resection of tumours
than for trauma surgery, particularly for gunshot injuries.14
Our idea is to repair the mandibular gunshot wound by inter-
nal distraction osteogenesis after either immediate or delayed
debridement depending on the condition of the injury.
Overall, internal distraction osteogenesis after debride-
ment might be one of the practical ways for the synchronous
reconstruction of bony and soft tissue in mandibular gunshot
injuries.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
The institutional ethics committee approved the study, and
patients’ gave their permission for publication of their data.
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