Medical Science Publication No. 4, Volume 1
MAXILLOFACIAL INJURIES*
A Supplement to the Discussion of Specific Primary Considerationsin Plastic Surgery,
presented by Colonel Bernard N. Soderberg
LIEUTENANT COLONELJAMES E. CHIPPS, DC
This is a supplement to Colonel Soderberg's discussion to further emphasizethe importance of early treatment of maxillofacial wounds. In the allottedtime, only two points will be considered. First, the reduction of bonefractures and closure of soft tissue injuries as much as possible at theprimary stage is of such benefit in the restoration of function and curtailmentof later major reconstructive procedures that it is essential to propermaxillofacial surgery that such treatment be rendered. Second, too fewpatients have received this beneficial primary treatment in the past andthe percentage can be improved upon in a future emergency.
Since Colonel Soderberg has adequately discussed the methods of primarytreatment, only the results in a few cases need be shown in making thefirst point. Some of these wounds were treated in the first few hours inKorea before marked inflammatory reactions had occurred. Others were firsttreated in Japan after a necessary short delay for preparation of the infectedwounds but before the response to injury had progressed to fibrosis.
Figure 1 illustrates a patient 14 days after sustaining severe stellatewounds of the right and left sides of the face with primary avulsion ofthe entire body of the mandible, the entire tongue, most of the suprahyoidstructures and most of the hyoid. The wound was repaired within the first6 hours in Korea. The scarring was minimal. The tissues were pliant. Musclefunction was almost normal.
Figure 2 illustrates the early postoperative result of treatment fora severe avulsive wound of the middle face. The closure was complete. Facecontour and muscle tone were maintained by treatment of the associatedavulsive mandibular fractures. This treatment was also accomplished ata 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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FIGURE1. Successful early closure after avulsion ofmandible and tongue, fourteenth post-wound day.
FIGURE2. Successful early closure of avulsive woundof middle face with loss of right body of mandible, twelfth post-woundday.
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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 repairand this most certainly would have been the case if early treatment hadnot been rendered. Actually, however, most of the tissues were not completelyavulsed and could be returned to place and sutured. Figure 4 is the earlypostoperative result and figure 5 is the result in the sixth postoperativeweek.
Figure 6 illustrates a patient on the third post-wound day after evacuationto Japan. There was avulsion of the anterior and right body of the mandibleand loss of considerable lip and chin tissue. Induration was marked. After5 days preparation, the wound was closed over an acrylic dental splintwhich maintained the mandibular stumps in position and prevented unduedistortion of the face following the closure. Figure 7 shows the postoperativeresult.
Figures 8 and 9 are the preoperative and postoperative illustrationsof a severe middle-face wound closed in Japan. The early surgical
FIGURE3. Middle-face injury,ROK soldier, first day of wound.
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FIGURE4. Same patient as figure3, second postoperative day.
closures in these cases greatly modified the eventual reconstructiveprogram.
Figure 10 shows a minor loss of deep tissue with extensive loss of superficialtissue. A skin graft was applied as soon as possible. Figure 11 illustratesthe early result. Although the eventual program of repair was not materiallyaltered by this early treatment, the patient benefited markedly by maintenanceof muscle function through prevention of undue fibrosis. In addition, therewere such secondary benefits as early return to a normal diet, reductionof the need for prolonged dressings and nursing care, shortened periodof chemotherapy and the like.
In all such cases, the psychological benefits from early treatment areas striking as the functional benefits and should be further discussed.However, in this limited presentation, the consideration of the benefitsof early treatment is closed with the statement that all who were primarilyengaged in maxillofacial work in the Korean war be-
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FIGURE5. Same patient as figure 3, sixth postoperativeweek.
FIGURE6. Unclosed wound, third day, with marked induration.
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FIGURE7. Same patient as figure 6, ninth postoperativeday after closure over an acrylic splint.
came convinced that the time to begin definitive repair of such woundsis during the first few hours. For practical purposes, this is at the mobilesurgical hospital level.
In considering how a higher percentage of patients in a future emergencymight receive beneficial primary treatment, a large series of inadequatelytreated maxillofacial casualties in the Korean war was reviewed and thepatients divided into six groups.
Group I
This group includes all those whose treatment was faulty or inadequateso that no material benefit resulted from the early treatment. Not allprimary closures of wounds were successful. Of the repaired wounds involvingthe mouth, the breakdown rate was sufficiently high to cause some observersto question the advisability of early wound closure. However, these breakdownsalmost invariably could be attributed to the failure to fully apply theprinciples of good surgery-
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FIGURE8. Unclosed wound of middleface, fifth day.
the principles that Colonel Soderberg has just discussed. A few pointsspecially applicable to maxillofacial wound management are further presentedhere.
A. Conservatism in Débridement. Although stressed in alldiscussions of maxillofacial wounds, this point requires repetition withparticular emphasis on conservatism in the management of bone fragments.Only rarely was soft tissue about a face wound observed to have been excisedbeyond the probable limits of devitalization, but mandibular fractureswere frequently seen to have been stripped clean of small bone fragments.At a general hospital in Japan, there were many cases in which certainbone fragments, given little chance of survival, were deliberately retainedbecause of their value in fracture management. Many such fragments survived(fig. 12) and the few sequestrations observed were not attended by particularlyharmful sequelae.
B. Tube Feeding. In addition to maintaining a better nutritionalbalance in the presence of oral wounds, a diet based on tube feedings
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FIGURE9. Same patient as figure 8, ninth postoperativeday.
instead of diets by mouth as tolerated is of material local value inreadying the wounds for closure and in shortening the postoperative healingperiods. 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 woundsrequirement an operation for débridement. It was often found duringthis procedure that, although the wound might not be entirely closed becauseof inflammation or tissue loss, the tissue about minor oral penetrationsor overlying exposed bone could be approximated without undue tension andwould heal during the period of preparation of the entire wound for delayedclosure. 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 minororal penetrations in the base of the wound were freshened, slightly underminedand lightly
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FIGURE10. Unrepaired wound, fourthday, with considerable loss of superficial tissue but minor loss of deeptissue and minimal penetration into mouth and mandible.
FIGURE11. Sixteenth post-woundday, same patient as Figure 10, after early skin graft.
closed. The wound was then treated as a one-surface superficial woundwhile being readied for skin graft and an early graft could be appliedwith increased hope of success. Similarly, adjacent soft tissue could
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FIGURE12. Severely comminuted fracture with deliberateretention of questionably vital bone fragments.
often be sutured over exposed bone during débridement and, ifcounterdrainage was established, the chance for bone survival was materiallyincreased.
D. Concomitant Treatment of Jaw Fractures. Figure 13 illustratesa patient with extensive repair of soft tissue but with no definitive treatmentof the associated mandibular fracture. The resulting depressed chin andelevated rami are typical of this type of injury. The lip is flaccid andthere is drooling. Displaced bone fragments and adjacent soft tissues arenow fixed. The facial and masticatory muscles have lost tone, partly fromanatomical displacement and partly from suppression of voluntary functionbecause of the pain associated with bone fragment movement.
If the bone is not generally aligned and moderately immobilized at thetime of the wound closure, it cannot be secondarily treated during thecritical period of fragment mobility without endangering the surgical repairduring manipulation. Thus, the fracture should receive treatment priorto the soft tissue repair and, if this is to be quickly accomplished inthe field, it is essential that the method of fracture
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FIGURE13. Soft tissue wound repairedwithout 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 aredisplaced from the main body of the bone and there are several fracturesthrough 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 endsof the rod are looped. The rod is then wired to the mandibular teeth beginningwith the anterior fragment, and each fragment is slipped slightly alongthe rod to contact with adjacent fragments (fig. 15). The last tooth oneach side is wired to the loops in the rod, anchoring the rod. The rodis then manually contoured until the result is a generally correct dentalarch that will contact the maxillary teeth. Isolated fragments are incorporatedinto the reduction by passing circumferential wires over the occlusal surfaceof adjacent teeth, over the rod and about the fragments. Figure 16 showsimmobilization completed by the application of intermaxil-
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FIGURE14. Typical missile fractureof mandible with 1/16 inch metal rod adopted for reduction.
FIGURE15. Metal rod wired to teeth. Isolated fragmentsincorporated by circumferential wire.
lary elastics between the wires holding the rod and wires applied inany of a variety of methods to the maxillary teeth. The small elasticsmay be cut from readily available latex surgical tubing. The number ofelastics is reduced to two on each side during transportation, a
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FIGURE16. Immobilizatin completed by intermaxillaryelastics to maxillary interdental wires.
traction sufficient to maintain comfortable occlusion without constitutinga danger of asphyxiation in the event of hemorrhage or emesis.
At general hospitals, time and facilities usually permit constructionof a splinting device during preparation of the wound for closure and thesplint illustrated in figure 17 can be substituted for the metal rod. Thissplint is constructed only against the lingual surface of the dental archand retained by steel wires looped about the cervices of the teeth andpassed through holes constructed in the splint at the interproximal embrasures.It is superior to most splints in ease of insertion and adequacy of reductionand immobilization. It may also serve as a support for the closure of anassociated soft tissue wound. Figure 18 illustrates a splint that bridgesa gap caused by the primary avulsion of bone substance and will supportthe soft tissue following wound closure.
Occasionally, instances of overtreatment of fractures in the early stageswere observed. Complex fracture gear often interferes with the surgicalclosure and precludes use of the important compression bandage. The bloodsupply to bone fragments, already markedly diminished, may be further impairedby excessive manipulation or intraosseous procedures in open reductiontechnics. Complex reduction and immobilization procedures can usually besafely deferred until the soft tissue wound has healed if the bone fragmentsare generally aligned and moderately immobilized by a simple device.
Many maxillofacial wounds can be managed by a general surgeon aloneand others can be managed by a rhinolaryngologist or an oral surgeon, butusually combined efforts are indicated if the maximum in sound treatmentis to be rendered. A more universal practice of
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FIGURE17. Acrylic splint constructed to lingual surfaceof dental arch and retained by interdental wires through holes in the splint.
this cooperation should result in a considerable reduction in the percentageof inadequacies of treatment. Dental officers were usually assigned tomobile surgical hospitals as Eighth Army policy but are not yet includedin the official tables of organization. The inclusion of a dental officershould be made official and, whenever possible, the dentist should be atrained oral surgeon.
Group II
This group consists of patients whose wounds were severe and apparentlyso specialized in nature that, frequently, no early definitive treatmentwas attempted. Progress notes that accompanied such patients usually showedthat the first receiving surgeons, after rendering essential life-savingand supportive care, had deliberately evacuated them without definitivetreatment in the hope that they would shortly reach designated centersfor specialized care. There were not enough such centers and evacuationwas not sufficiently rapid to provide the indicated early treatment atthe time that it could best be done.
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FIGURE18. Acrylic splint, constructed to support thelower lip after closure and to immobilize mandibular stumps after avulsivefracture.
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 designationof rear area specialty centers but this also would require a positive programfor priority evacuations. A third, and more practical, solution is to showall concerned personnel through educational programs that most of the essentialsof early wound care such as débridement, closure of tissue overexposed bone with counterdrainage, fracture immobilization and adequateuse of supporting bandage, need not await a specialist.
Group III
At the other extreme from those with severe injuries were those whoseinjuries were essentially superficial but so multiple as to require tedious,time-consuming procedures for repair. Frequently, such patients were nottreated at forward installations because of the more apparent urgency fortreatment of more seriously wounded patients. However, maxillofacial wounds,even when physically superficial, always have psychological and socialimplications 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 suturebecome contractures that require evacuation and complex plastic surgeryafter a few days healing. Dirt and debris blown through the skin that mightinitially be removed by a thorough sponging with detergents become "blasttattoos" that have kept many patients hospitalized in plastic centersfor months. Figures 19 and 20 illustrate the probable prevention of a "tattoo"by cleansing a wound at an evacuation hospital in Korea shortly after thewound was incurred.
In addition to increased education as to the desirability of early managementof maxillofacial injuries, the solution in this group also requires thatadequate personnel be available at the forward hospitals. It is suggestedthat this personnel might be obtained in time of need from division dentalpersonnel. There are 18 dental officers in the infantry division and theirprimary duties are materially altered when the division is in actual combat.The interests of the division
FIGURE19. Markedly dirty wound of face.
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FIGURE20. Same as figure 19 after"tattoo" preventive cleanup and early repair.
might best be served if two or three of these dental officers were detachedduring periods of combat and assigned to the mobile surgical hospital inmost direct support of that division. Even when they lack formal surgicaltraining, such officers can be readily trained by the hospital's staffto be of material aid during periods of stress.
Group IV
This group consists of those with multiple wounds whose maxillofacialtreatment was deferred primarily because of a more severe injury of head,chest, or the like. Occasionally, this deferment was actually dictatedby the patient's physical condition but more often it was due to overspecializationof 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 becauseadvanced personnel did not understand that such treatment was expectedfrom them. It would seem that this group could be eliminated merely bythe publication of directives or other minimal attempts at education, butsuch attempts have been misunderstood in the past.
As an example, an administrative letter from a higher headquarters isquoted in part:
"Maxillofacial Injuries
The principle that definitive treatment of patients with maxillofacialinjuries should be provided as early as feasible is well established. Acontinuing problem exists in the delayed evacuation of these cases to specializedtreatment centers. . . . Stations should evaluate cases promptly to determinethat 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 exceptin specialty centers, an interpretation just the opposite from the letter'sintent.
As a second example, an attempt was made in Japan to analyze the preventablecauses of breakdown of repaired maxillofacial wounds and publicize thisanalysis in an effort to improve the results. Shortly, patients evacuatedto Japan from a hospital which had previously accomplished excellent treatmentbegan to arrive without definitive surgery. After inquiry, one of the surgeonsconcerned replied that he had heard the repairs were breaking down so hehad stopped performing them. Again, this was an interpretation just theopposite from the one intended.
In late 1951, a brief course in oral surgery for dental officers fromevacuation and mobile surgical hospitals was established at Tokyo ArmyHospital. The result was an immediate improvement in the management ofmaxillofacial casualties, not because a great deal of oral surgery hadbeen taught but because the officers attending the course were able toobserve patients at both ends of the evacuation chain and learn specificallywhat was expected of them at forward hospitals.
Group VI
This last group consists of those who were evacuated without treatmentbecause 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 dentalofficers to mobile surgical hospitals while the division is in combat wouldprovide 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 anddegree of definitive treatment accomplished in the first few hours afterthe injury. Compared to the past, there was marked improvement in the managementof such injuries in the Korean war but still further improvement can beattained.
After analysis of a series of untreated maxillofacial patients, it isseen that education of Medical Department personnel as to the essentialityof early treatment is the chief solution to the problem. One desirablemethod of instruction can be based on a policy of assigning replacementspecialty personnel to advanced hospitals only after short periods of observationat rear area specialty centers in the evacuation chain.
The problem of the shortage of personnel at forward hospitals duringperiods of heavy casualties can be partially answered insofar as maxillofacialcasualties are concerned by the temporary assignment of dental officersto the hospitals from combat divisions.
Acknowledgments
The patients illustrated in figures 1 and 2 were treatedat the 8063 MASH by Dr. James R. Broun, Pendleton, Oregon. Figures 3, 4,5, 19, and 20 illustrate patients treated at the 121st Evacuation Hospitaland 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 casualtiesat Tokyo Army Hospital. The acrylic splint described in the text was firstdesigned by Lieutenant Colonel James B. Neil, DC.
