Soft tissue wounds of the maxillofacial region: clinical guidelines

List of Abbreviations

TMJ – Temporomandibular joint

RTA – road traffic accident

MFT – facial bones

SSI – surgical site infection

PAP – perioperative antibiotic prophylaxis

SAT – subcutaneous adipose tissue

SDW – surgical debridement of wounds

MFR – maxillofacial region

TBI – traumatic brain injury

OMHC – oral mucous membrane

CTB and CTFB – computed tomography of the brain and computed tomography of the facial bones

CBCT – cone-beam computed tomography

MRSA – methicillin-resistant Staphylococcus aureus

ABT – antibiotic therapy

eAT – empiric antibiotic therapy

CP – clinical guidelines

PT – physical therapy

Terms and Definitions

Wound – disruption of the integrity of the skin or mucous membranes.

Contusion – soft tissue injury resulting from the short-term action of a traumatic agent, not accompanied by wound formation.

Strain – soft tissue injury caused by a tensile force that does not disrupt the anatomical continuity of elastic structures (ligaments, tendons, muscles).

Rupture – disruption of the anatomical integrity of tissues caused by a force exceeding their elastic capacity.

Injury – a common type of trauma, i.e., the result of interaction between the human body and wounding agents.

Firearm trauma – occurs when a person is exposed to various types of weapons: wounding projectiles of small arms and explosive munitions.

Damage – the result of exposure to wounding agents, damaging factors, or surrounding objects on specific tissues, organs, or systems of the human body.

Combat trauma – bodily injury arising from the action of any means (mechanical, thermal, biological, chemical), ionizing radiation, or combined effects used as weapons.

Oral hygiene – a set of measures aimed at reducing the amount of dental deposits.

Imbibition – impregnation and characteristic staining of tissues and organs by substances dissolved in them.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Trauma (from Greek "trauma" – wound) is defined as the effect of environmental factors on the human body that disrupts the anatomical integrity and physiological functions of organs and tissues, accompanied by local and general systemic reactions [1, 2, 3, 4].

Craniomaxillofacial trauma is a simultaneous injury to the soft tissues of the maxillofacial region and/or the bones of the neurocranium, brain, facial skeleton, organs of vision, and ENT organs, characterized by the onset of neurological disorders, impaired visual functions, aesthetic defects, and a high risk of complications [5].

Gunshot wound – injury to tissues and organs with disruption of the integrity of their integuments (skin, mucous membrane) caused by a ballistic agent (bullet, shrapnel), characterized by a zone of primary and secondary necrosis, as well as primary microbial contamination.

A distinctive feature of maxillofacial trauma in children is that it is accompanied not only by significant acute-period injuries but also by long-term consequences associated with delayed development and growth of soft tissues and facial bone structures, leading to post-traumatic deformities [6, 24].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Maxillofacial trauma in adults is a pressing modern medical and social problem, the significance of which increases year by year. This is determined by the continuous rise in the incidence of maxillofacial injuries and the increasing severity of maxillofacial trauma and polytrauma. Furthermore, trauma ranks 3rd in the overall adult mortality structure, and 1st among individuals of working age. In recent years, the number of combined injuries and severe polytraumas resulting from motor vehicle accidents, criminal acts, and natural disasters has increased significantly. Traffic accidents entail particularly severe consequences due to global urbanization. Facial injuries are most frequently combined with traumatic brain injury. Despite significant progress, the treatment of patients with facial bone fractures and the prevention of complications remains an extremely difficult and far from resolved problem. The seriousness of the problem is due to the significant proportion of elderly and senile patients, patients with chronic and concomitant diseases, and individuals of low social status. Firearm trauma is also a variant of maxillofacial injuries in the adult population. The incidence of gunshot injuries to the face and jaws in peacetime is approximately 0.5%. Criminal trauma ranks first in the structure of gunshot wounds, suicide attempts rank second, and careless and unskilled handling of firearms ranks third. The time of admission for such wounded patients ranges from 6 hours post-injury up to 5–7 days if patients arrive from remote areas.

All parents encounter childhood injuries sooner or later. A child may sustain their first maxillofacial injury during childbirth as a result of mechanical trauma, which is referred to as birth trauma. Rapid or prolonged labor, a large fetal head size relative to the pelvis, and applied artificial obstetric assistance may serve as the cause. Characteristic injuries of the newborn include trauma (contusion, hematoma) to the facial soft tissues, fractures of the neurocranium and facial bones, and facial nerve injuries [7, 8, 9, 10].

The nature of maxillofacial injuries largely depends on the child's age. Unlike an adult, a child has a lower body weight and height, elastic skin, and a large volume of subcutaneous adipose tissue, which mitigates the traumatic impact on facial structures during a fall [37]. Children most commonly experience injuries to the facial and oral soft tissues, significantly less frequently dental injuries, and even more rarely facial bone fractures. Domestic accidents rank first in prevalence. This may be due to a lack of safe home conditions for the child, inadequate adult supervision, and children lacking sufficient skills to interact with the surrounding world or the ability to assess dangerous situations sensibly. Road traffic accidents rank second [5]. In preschool age, children are injured from falls during play, which is more frequently observed in the spring and summer periods [9]. In children under 5 years of age, soft tissue injuries of the face and oral cavity predominate in the form of abrasions, contusions, and wounds. As the child grows, school, sports, automobile, and unorganized play accidents become more common, causing maxillofacial trauma combined with neurotrauma [8]. After 6–7 years of age, an increase in the number of children with dental and jaw injuries is noted. Older children, particularly adolescents, are characterized by injuries from falls from heights, active games, automobile accidents, falls from bicycles and other individual vehicles, as well as injuries sustained from being struck in the face during disputes with peers. Dental and facial bone fractures, as well as extensive lacerated and contused wounds of the facial soft tissues, begin to occur more frequently in this group. In addition to the increased activity of children and adolescents during this age period, there are a number of anatomical and functional age-related changes in the body of a pubertal adolescent. For example, with age, the amount of subcutaneous adipose tissue in the child's face decreases, and the elasticity and shock-absorbing capacity of facial bones (such as the mandible) diminish due to increased bone tissue mineralization, a decrease in the cushioning and softening resistance of the periosteum against traumatic force, and a number of other factors. After 14 years of age, the pattern of maxillofacial injuries in children differs little from that in adults. Temporomandibular joint dislocations are characteristic of older children, especially adolescents.

Over the past two decades, according to data from urban pediatric maxillofacial inpatient facilities, animal-inflicted injuries have increased nearly fivefold. The overwhelming majority are dog bites involving soft tissue damage to the face, and less frequently injuries to the teeth, alveolar process, and even jaw fractures. Such wounds are inflicted significantly less often by other animals: cats, rodents, horses, as well as bites inflicted by other persons or self-inflicted injuries ("bites") by the child [13, 14].

1.3 Epidemiology of the Disease or Condition

Over the past 5 years, the incidence of trauma among the adult population has increased by 5.7%, disability by 31.3%, and mortality by 40.6%. According to various authors, the proportion of patients with maxillofacial trauma among all inpatient dental patients ranges from 21% to 40%. Maxillofacial defects occur most frequently in individuals of working age from 18 to 50 years (91%). Trauma shows seasonality, with the number of patients presenting with facial injuries increasing during the summer and autumn months. This is explained by an increase in the frequency of motor vehicle accidents, street trauma, and agricultural injuries. Studies have shown that the leading causes of maxillofacial trauma are domestic accidents (83%), motor vehicle accidents (12%), occupational injuries (4.5%), and sports-related injuries (0.5%). Notably, there has been an increase in the number of gunshot wounds to the maxillofacial region in recent years. The proportion of mandibular fractures ranges from 77% to 95%, maxillary fractures from 3% to 20%, and fractures of both jaws from 2% to 8%. Maxillofacial injuries are distributed by localization as follows: soft tissue facial defects 19%, zygomatic bone fractures 15%, nasal bone fractures 4.5%, maxillary fractures 3.5%, and mandibular fractures 58%. A certain correlation has been established between the time elapsed before seeking care at specialized facilities, the localization and type of injury, and the nature of the defect. Registry analysis revealed that on the first day after trauma, approximately 92% of patients with facial soft tissue defects seek care at trauma centers, compared to 89% with gunshot defects, 68% with nasal bone fractures, 69% with multiple facial bone fractures, and 58% with double mandibular fractures. Patients with zygomatic bone fractures (32%), isolated mandibular fractures (18%), and multiple facial bone fractures (31%) present at later stages, up to 10 days post-injury.

The epidemiology of combat trauma varies across the world and depends on numerous external factors. For instance, prior to February 2022, the statistics for maxillofacial gunshot wounds in Russia were relatively low, averaging 0.5% of all admissions to maxillofacial inpatient departments. Following the launch of the special military operation in Russia, this figure increased significantly.

Patients with maxillofacial trauma account for up to 25–30% of all patients treated in maxillofacial inpatient departments. The incidence of maxillofacial trauma in children is 10 cases per 1,000 pediatric population. However, patients with maxillofacial trauma account for a smaller proportion in pediatric maxillofacial surgery clinics, ranging from 4.1% to 10–11% of the total number of hospitalized patients. The majority of children with maxillofacial injuries are treated on an outpatient basis or do not seek medical attention [6, 14].

The incidence of animal bite wounds among all traumatic injuries in the population is up to 1%. Of these, the face, scalp, and neck are affected in 15–32% of cases. Between 160,000 and 200,000 human dog bites are registered annually in the Russian Federation. Children aged 5 to 14 years are the most frequent victims [16].

1.4 Features of Coding the Disease or Condition

S00.1 Contusion of eyelid and periocular area

S00.2 Other superficial injuries of eyelid and periocular area

S00.5 Superficial injury of lip and oral cavity

S01.1 Open wound of eyelid and periocular area

S01.4 Open wound of cheek and temporomandibular area

S01.5 Open wound of lip and oral cavity

S01.7 Multiple open wounds of head

S01.8 Open wound of other parts of head

S03.4 Sprain and strain of joint and ligaments of jaw

S08.1 Traumatic amputation of ear

1.5 Classification of the disease or condition

Based on the etiology of maxillofacial trauma, the following groups can be distinguished:

1. Domestic trauma;

2. Transport trauma;

3. Street trauma;

4. Occupational trauma;

5. Sports trauma.

Classification of maxillofacial soft tissue injuries:

1. Contusions;

2. Abrasions;

3. Hematomas;

4. Wounds (by type of wounding agent):

   - stab wounds;

   - incised wounds;

   - contused wounds;

   - chop wounds;

   - bite wounds;

   - gunshot wounds.

Classification by external appearance of maxillofacial wounds:

1. Linear;

2. Stellate;

3. Flap;

4. Scalp wounds;

Based on the nature of maxillofacial tissue damage, the following main groups of patients can be distinguished:

1. With injuries to the facial soft tissues and oral cavity (contusions, hematomas, abrasions, hemorrhages, wounds)

2. With dental injuries (contusions, dislocations, fractures)

3. With fractures of the facial bones (mandible, maxilla, zygomatic bone, nasal bones, fractures of multiple adjacent bones - "complexes")

4. With combined maxillofacial tissue injuries (teeth and bones; soft tissues and teeth; soft tissues and jaws)

5. With injuries to other systems and organs (e.g., combined craniomaxillofacial trauma)

I. Mechanical injuries of the upper, middle, lower, and lateral zones of the face

1. By localization:

Facial soft tissue injuries involving:

a) tongue;

b) salivary glands;

c) major nerves;

d) major vessels.

2. By nature of the wound:

a) through-and-through;

b) blind (penetrating without exit wound);

c) tangential;

d) penetrating into the oral cavity, nasal cavity, maxillary sinus;

e) non-penetrating into the oral cavity, nasal cavity, maxillary sinus;

f) with tissue defect - without tissue defect;

g) primary - concomitant;

h) single - multiple;

i) isolated - combined.

3. By clinical course of the wound healing process:

a) complicated;

b) uncomplicated.

4. By mechanism of injury:

A. Firearm injuries:

a) gunshot;

b) shrapnel;

c) spherical (ball);

d) flechette.

B. Non-firearm.

II. Combined injuries.

1.6 Clinical presentation of the disease or condition

Contusion – occurs under the influence of a short-term traumatic factor (blunt object). A closed soft tissue injury of the face without violation of their integrity with possible restriction of function. Contusions are characterized by progressive edema at the site of injury, followed by a bluish bruising, which then acquires a dark red or yellow-green shade. At the site of soft tissue contusion, a rather dense, painful area resembling an infiltrate can be determined. This is the result of tissue imbibition with exudate. Signs of inflammation in contusions are absent or appear late.

Abrasion, scratch – the mildest soft tissue injuries, the basal layer of the dermis is not damaged, not accompanied by bleeding, but are initially infected. Main clinical signs: pain, violation of the integrity of the skin and oral mucosa, edema, hematoma. Formed by the action of an object tangentially, at an angle to the skin surface.

Hematoma – an accumulation of blood extravasated from damaged vessels and dissecting the tissues. Translucent through the skin, it gives a bluish or blue-purple color. With a superficial location of the hematoma (subcutaneous), they become noticeable almost immediately after receipt. With a deeper localization of hematomas (intermuscular and interfascial), they can appear a day or more later.

By clinical course: simple, encysted, suppurative, pulsating.

By the type of extravasated blood: arterial, venous, mixed.

By localization: subcutaneous, intermuscular, interfascial.

Wound – violation of the integrity of the skin and mucous membranes with damage to the underlying tissues. The main signs of wounds: pain, bleeding, infection [47].

Puncture wounds have an entrance opening, a wound channel, and sometimes an exit opening. The depth of the wound always exceeds its length. Since tissue damage by a stabbing object is based on splitting and compression of tissues, the divergence of the wound edges is insignificant, bleeding is moderate, but the formation of hematomas and pockets not corresponding to the size of the external wound is possible.

The puncture type of wound in the adult population is most often encountered as a result of blows with household stabbing objects (knife, awl, screwdriver, etc.), and in dental practice – with an elevator. When soft tissues are injured with a dental elevator, microbial contamination of the wound is significantly pronounced. With puncture wounds, the introduction of a foreign body is possible, which is also observed with gunshot wounds.

This type of injury is quite common, compared to other age groups, in children aged 1 to 3 years, when the child's oral cavity is injured by a sharp object (pencil, pen, fork, etc.).

Incision wound (cut) has a linear shape, smooth edges, which, due to skin elasticity and under the influence of traction of damaged muscles, diverge, causing gaping of the wound. The length of the wound always exceeds its depth. As a result of the development of edema around the wound, its gaping increases even more, which creates the impression of a tissue defect. They bleed heavily and are mildly painful. With an incision wound, the effect of microbial contamination is insignificant.

These types of wounds in the pediatric clinic are represented almost exclusively by wounds received from broken glass as a result of car accidents or by a child hitting their face on glass fragments due to carelessness (hitting the face on a glass door), while the variability of the clinical picture of this type of wound in an adult patient is diverse. In an adult patient, incision wounds occur as a result of occupational carelessness due to non-compliance with safety regulations. Also, incision wounds are the consequence of domestic conflicts.

Contused wounds occur from the action of blunt objects. They are accompanied by the formation of abrasions, hematomas, progressively increasing edema with severe pain syndrome. The wounds have an irregular shape, with crushed edges, sometimes with a zone of marginal necrosis. In contused wounds, severe bleeding is rarely observed, wound gaping is moderately expressed, but its microbial contamination occurs more often. This is the most frequent type of wound as a result of mechanical injuries of the maxillofacial region in children of all age groups.

Chopped wound, like an incision wound, has a linear shape, smooth edges, and differs from the latter by more extensive areas of soft tissue damage. Often, chopped wounds are accompanied by damage to facial bones and soft tissues and penetrate into the nasal cavity, oral cavity, and maxillary sinus, and the impact of microbial contamination in such wounds is significant. Bleeding can be profuse.

Bite wounds. Wounds from animal and human bites resemble lacerated and lacerated-contused wounds in character. Tooth marks may be found. Most often they are observed in the nose, ear, or lips. With strong compression of the teeth, traumatic amputation of the tissues of the damaged organ can occur. Bite wounds are always contaminated with pathogenic microflora. Characteristic features include: pronounced hematoma, edema of the damaged area, often crushed, uneven edges of the wound with detachment of surrounding soft tissues, bleeding heavily. As a rule, such wounds are deep, extensive, irregular in shape and are accompanied by tissue loss [14, 15, 52, 53].

Gunshot wound – damage to tissues and organs with a violation of the integrity of their integuments (skin, mucous membrane) caused by a gunshot agent (bullet, shrapnel), characterized by a zone of primary and secondary necrosis, as well as primary microbial contamination. Gunshot injuries are wounds caused by one or more damaging factors when firing all types of firearms, explosion of ammunition, shells, and explosives. All gunshot injuries are characterized by a combined mechanical, thermal, and chemical damaging effect.

Linear wounds with abraded ends – occur from the action of the edge of a blunt object with a blunt-edged surface.

Stellate wounds occur from the action of a wide flat surface of a blunt object, as well as from the action of the apex of a blunt object with a blunt-edged surface.

Flap wound is formed when a hard blunt object strikes at an angle to the body surface, followed by displacement and detachment of the skin in the form of a flap.

Scalp wounds (scalping) are characterized by the formation of a soft tissue flap that detaches from the underlying bone. Most frequently, scalp wounds are localized in the scalp area and superciliary region, but more complex soft tissue defects caused by the detachment of a significant part of the face are also encountered. The edges of the wounds during scalping are uneven, the shape is irregular, bleeding is profuse, and infection is significant.

Lacerated wounds have an irregular shape with uneven edges. Ruptures of underlying tissues with the formation of intratissue pockets and cavities may be observed. The cause of lacerated wounds is the action of blunt objects with a sharp edge. Bleeding is moderately expressed, the edges gape, the wound is infected.

According to the localization of wounds on the face, 6 main areas can be conditionally distinguished:

- frontotemporal;

- orbital and infraorbital;

- nasal region;

- perioral region;

- mental region;

- lateral surface of the face (parotid-masseteric, zygomatic, buccal regions).

Clinical manifestations of facial wounds in both adults and children are diverse. A rapid increase in collateral edema and significant bleeding are characteristic. Due to the functional features of the mimic muscles, wounds often have a gaping appearance, which does not always correspond to the severity of the injury.

Mechanical trauma to the oral mucosa can be acute and chronic.

Clinical picture of conditions/diseases in acute trauma of the oral mucosa.

Acute mechanical trauma is more frequently diagnosed in children, caused by impacts, biting the tongue during a fall, or injury to the oral mucosa from toys, pencils, or other sharp or cutting objects. Injuries caused by the sharp edges of broken teeth or a prematurely erupted tooth are also common. Acute mechanical trauma can result from accidental biting during eating, tooth brushing, or dental procedures. Clinical presentation: lesions of the lips, tongue, and soft and hard palate predominate. Manifestations of acute mechanical trauma may include hematoma, abrasion, erosion, or a wound. In cases of traumatic oral mucosa injuries in young children: the child refuses to eat, general condition worsens, pain during speech and swallowing increases, temperature rises, and signs of regional lymphadenitis appear. At the site of trauma, the oral mucosa surface is hyperemic and edematous, with white epithelial shreds and sometimes small hemorrhages. Often, a more thorough examination reveals fragments of a foreign body. An example of acute mechanical trauma to the oral mucosa in children is erosion resulting from lip biting after dental procedures performed under anesthesia, which is localized on the mucosa of the oral commissure or lower lip.

Clinical presentation of conditions/diseases in chronic oral mucosa trauma.

Chronic mechanical trauma is most characteristic of the adult population. This trauma occurs from prolonged exposure to a mild irritant and most frequently causes lesions of the oral mucosa. Various types of chronic mechanical trauma are more often observed in elderly individuals against the background of a reduced vertical dimension of occlusion, decreased mucosal turgor, and the presence of dental prostheses in the mouth. Traumatic factors may include sharp edges of teeth, fillings, dental calculus, orthodontic appliances, bad habits, and occupational hazards (e.g., habitual biting, chewing of the mucosa, smoking, needle biting in seamstresses). Poor-quality dentures (rocking removable appliances, rough, deep-set borders of acrylic plate dentures, bridge prostheses resting on the alveolar ridge) frequently exert a traumatic effect on the mucosa. Trauma to the tongue and cheeks is caused by limited dentition defects that promote mucosal entrapment and friction. A long-standing mechanical irritant dulls the sensitivity of the oral mucosa, so acute pain symptoms may be absent. The sparse clinical picture (a feeling of awkwardness, discomfort, soreness, or mucosal swelling) does not cause concern in patients, leading to continued traumatic exposure.

Chronic mechanical trauma is the result of prolonged exposure to irritating factors. Causes: injury to the oral mucosa by sharp edges of carious teeth and their roots, parts of orthodontic appliances, prematurely erupted primary teeth, defective fillings in the cervical area and on the proximal surfaces of teeth, trauma to the mucosa by teeth in dentofacial anomalies, bad habits, and the adhesion of thin and sticky foreign objects to the hard palate. Clinical presentation: lesions may present as erosion, ulcer, or leukoplakia, localized in the area of the lips, tongue, and cheeks. If left untreated, chronic focal purulent inflammation develops, culminating in the appearance of a decubital (traumatic) ulcer. Traumatic ulcers vary in size and depth, have raised edges relative to the surrounding mucosa, the base of the ulcer is covered with a pale yellow coating, and the surrounding mucosa is hyperemic and edematous. A tendency toward granulation tissue development and proliferative phenomena is characteristic. Palpation of the ulcer may elicit pain. The general condition of both adults and children is typically undisturbed. Adults and children usually seek medical attention when the process exacerbates as a result of ulcer infection, accompanied by increased swelling of surrounding tissues and tenderness of regional lymph nodes. Diagnosis is difficult in a number of cases.

Bednar's aphthae are the result of oral mucosa lesions in infants of the first months of life and, much less frequently, at an older age. They occur in premature, debilitated, frequently ill children who are bottle-fed or breastfed, or suffer from congenital diseases. The appearance of aphthae is associated with damage to the palatal mucosa under the pressure of a long, rigid feeding bottle nipple or a coarse pacifier against the background of poor oral hygiene and rough care (wiping) of the oral mucosa, most commonly in infants. The aphthae are located at the border of the hard and soft palate, over the pterygoid hamuli of the sphenoid bone, closer to the midline, predominantly on one side, less frequently on both sides.

The clinical presentation and course of the process depend on the location of the lesion, the patient's age, the intensity of the irritating factor, the body's reactivity, and oral hygiene. As a result of prolonged mechanical trauma, a picture of chronic inflammation develops in the oral mucosa with a predominance of either alteration or proliferation, depending on individual tissue resistance. Chronic mechanical trauma developing with tissue damage (alteration). The most frequent lesion is traumatic erythema (traumatic stomatitis). This initial response of the mucosa to a damaging factor manifests as localized catarrhal inflammation and a hyperemic spot. The mucosa of the lips, cheeks along the bite line, and lateral surfaces of the tongue are most susceptible to this trauma. Traumatic stomatitis caused by wearing removable plate dentures (traumatic denture sores) may present as hyperemic, acutely painful spots in specific areas of the denture-bearing mucosa. Another variant of oral mucosa lesions in adult patients is traumatic desquamation. It develops under the continuous influence of a traumatic agent. The most superficial layers of the oral mucosal epithelium are damaged, causing desquamation, i.e., superficial shedding of epithelial cells. Traumatic desquamation can be found in areas of the oral mucosa most susceptible to trauma, but this process is most commonly diagnosed on the tongue. In the zone of trauma (sharp tooth edge; dentition defect where the tongue is trapped), increased shedding of filiform papillae is noted, forming a focus of desquamation. Clinically, the desquamative area, devoid of papillae, appears against the whitish background of the dorsum of the tongue as a slightly depressed, limited reddish spot, soft and painless or slightly sensitive upon palpation. It is always strictly localized to the zone of action of the traumatic factor. Traumatic erosion is also one of the most frequently encountered oral mucosa pathologies in the adult population. Erosion forms on an inflamed area of the oral mucosa under continued traumatic exposure.

Clinically, traumatic erosion presents as a painful superficial epithelial defect covered with a fibrinous coating. Traumatic erosions developing under plate dentures are characterized by sharp pain.

Clinical presentation of conditions/diseases in maxillofacial gunshot wounds.

The clinical course of gunshot injuries in the maxillofacial region differs significantly from that of wounds in other areas. This is due to at least two anatomical and physiological features: on the one hand, the rich vascularization of the facial soft tissues, and on the other hand, the extensive contamination of the oral cavity with highly pathogenic microflora. Given these features, there are a number of characteristic peculiarities in wounds of the soft tissues and bones of the face.

1. A well-developed capillary network and the presence of loose cellular tissue in the subcutaneous and submucosal layers in gunshot wounds of the lips and perioral region cause rapid and significant development of soft tissue edema.

2. Wounds of the lips, especially the upper lip, and the perioral region are characterized by gaping of the edges,

often simulating a true tissue defect. Injury to the lower lip and the corner of the mouth leads to skin maceration caused by continuous drooling, which increases when a true defect of the lower lip occurs.

3. The lateral regions of the face, which have a lower regenerative capacity compared to the tissues of the lips, eyelids, and other areas, undergo greater destruction with the formation of deep pockets and significant hemorrhages. Injuries to the parotid gland and facial nerve further aggravate the nature of the trauma, subsequently leading to facial disfigurement due to paralysis of the facial muscles and the formation of salivary fistulas. Injury to the facial nerve leads not only to cosmetic impairments, but also to severe functional disorders. Lower eyelid lagophthalmos is complicated by increased lacrimation and the development of conjunctivitis. Against the background of multiple soft tissue and facial bone injuries, trigeminal nerve wounds may go unnoticed. Meanwhile, such an injury is accompanied by a number of irreversible functional disorders of the maxillofacial system, manifested by the loss of all types of superficial sensitivity (pain, temperature, tactile) and, as a consequence, by a disruption of the masticatory act. Due to this, on the side of the trigeminal nerve injury (as a result of inadequate masticatory function), dental calculus is abundantly deposited, and conditions arise for the development of gingivitis and periodontitis. Under unfavorable conditions (compression of trigeminal nerve branches by bone fragments, bone callus, etc.), the occurrence of traumatic neuritis and symptomatic neuralgia is possible.

Wounds of the submandibular region, which has a significant layer of subcutaneous adipose tissue, always proceed with pronounced edema, infiltration, and hemorrhage, with a tendency to develop purulent inflammatory processes. Suppuration occurs more often when foreign bodies are present in the wound. Wounds of the submandibular region are frequently accompanied by damage to the submandibular salivary gland, pharynx, larynx, as well as large neck vessels.

Gunshot wounds of the soft tissues and bones of the facial skeleton often lead to damage to a large number of blood vessels. Along with major vessels, the extensive venous network and small arteries of the face and neck are primarily damaged. The consequence of such injuries is the occurrence of interstitial hemorrhages. Reaching large sizes, they can spread to the anterior mediastinum, causing breathing difficulties due to compression and displacement of the trachea by the hematoma. The most frequent complication is the development of aspiration asphyxia by blood and saliva.

The clinical course of a wound and its outcome are determined by the volume of affected tissues and the mechanism of injury (type of wounding projectile). Gunshot wounds of the maxillofacial region are often accompanied by damage to large nerves and vessels, concussion or contusion of the brain, damage to the eyeballs, trachea, larynx, and auditory organs, i.e., they quite frequently classified as combined injuries.

The anatomical and physiological features of the maxillofacial region determine the clinical manifestations of gunshot wounds in this area. They can either favor the course of the wound process or complicate it. All sense organs, the initial parts of the respiratory, digestive, and speech organs are located in the maxillofacial region. All this determines the following features of facial wounds.

Disfigurement leads to aesthetic impairments (including facial expressions), which affects a person's communication in society and impacts the emotional and psychological status of the wounded person. Disfigurement is the cause of depression in the wounded person and sometimes suicide. This circumstance has led to the recommendation not to hang mirrors in maxillofacial departments.

The discrepancy between the wounded person's external appearance (disfigurement) and the severity of the injury. This may lead to a false perception of the victim's hopelessness and failure to provide aid as a matter of priority. Moreover, about 20% of those with facial wounds lose consciousness. At the same time, mortality among victims with facial injuries is low. On the other hand, the external picture of a facial injury may be disproportionate to the severity of the course and outcome of the wound. For example, through-and-through wounds of the floor of the oral cavity with minor visible destruction frequently ended in fatal outcomes. This feature must be taken into account when conducting evacuation measures and explanatory work among personnel for the rapid evacuation of the wounded person and the prevention of death from hemorrhage.

Impairment of mastication, swallowing, and speech functions. These disorders exacerbate neuropsychiatric disorders and create prerequisites for the disruption of adequate nutrition, metabolism, and dehydration of the body. On the battlefield, speech impairment can be the reason for failure to provide aid, especially if the wounded person is in an unconscious state and therefore unable to report about themselves and may be mistaken for dead.

Abundant blood supply to the maxillofacial region. On the one hand, it can lead to significant hemorrhage, the development of phlebitis and thrombophlebitis with the spread of infection into the cranial cavity and mediastinum. On the other hand, it promotes good long-term wound healing.

Rapid dehydration of the body. Dehydration aggravates the condition of the wounded person. It occurs as a result of a compromised oral seal, swallowing disorders, hypersalivation, and the inability to quench thirst in the usual way. The problem of dehydration is especially acute in hot climates.

Helplessness. The inability to signal oneself by voice, the need for special nutrition and care.

Threat of various types of asphyxia. Most frequently occurs in those wounded in the face due to damage to the larynx, oral cavity and nasal organs, as well as fractures of the mandible.

Loss of consciousness and the development of traumatic shock are consequences of concussion or contusion of the brain, intracranial hematomas, and skull base fractures. Most frequently, this complication occurs with injury to the maxilla.

Proximity of vital organs. Facial wounds often lead to combined injuries of such organs as the brain, upper respiratory tract, and large vessels, with corresponding clinical symptoms and the need to provide emergency and urgent care.

Presence of teeth. On the one hand, teeth play a positive role: they help diagnose the nature of the fracture by the occlusion, and serve as support for splinting structures. On the other hand, they become secondary wounding projectiles, conductors of infection into the surrounding soft and bone tissue, and foreign bodies that can be aspirated into the respiratory tract and form a lung abscess.

The possibility of unequal course and outcome of identical injuries of the mandible and maxilla. This depends on the different structure of their bone tissue. Thus, a blind shrapnel wound of the mandible turned out to be fatal 2.5 times more often than the same injury to the maxilla, while through-and-through bullet wounds of the maxilla were fatal 7 times more often than shrapnel wounds.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

Soft tissue wounds of the maxillofacial region are diagnosed based on complaints, anamnestic data, physical and instrumental examination.

2.1 Complaints and Anamnesis

The collection of complaints and anamnesis is carried out from the victim and accompanying persons, or from the ambulance delivery sheet, according to the statements of police and traffic police representatives, etc.

• The mechanism, date, and time of the injury are established. If the injury was received as a result of beating, then in the medical documentation, it is recommended, to ensure the subsequent implementation of procedural actions and punishment of the perpetrators, to note who inflicted the injury, their full name, and the circumstances of receipt; if the injury was received as a result of a traffic accident, the circumstances and the state registration plate of the vehicle are noted [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• When collecting the anamnesis, it is recommended to clarify, for a more accurate assessment of the victim's condition and diagnosis, whether there was a fact of dizziness, nausea, vomiting, loss of consciousness, breathing difficulty, throat tickling, the sensation of a "lump" in the throat, hoarseness of the voice, cough with soot-containing sputum, thirst, chills, decrease or increase in body temperature, weakness, insomnia, loss of appetite, dyspeptic symptoms, skin itching, the presence of skin depigmentation, post-burn scars and/or scar deformities. A significant proportion of patients with TBI are admitted in a moderate and severe condition, one of the symptoms of which is various types of amnesia [38, 63].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

2.2 Physical Examination

During the examination, it is recommended to adhere to the principle of maximum informativeness with minimal invasiveness.

• In all patients with maxillofacial trauma, it is strictly recommended to perform a physical examination to clarify the diagnosis and determine the treatment tactics [67]:

- assessment of the patient's general condition;

- inspection of the maxillofacial region, including the oral cavity;

- palpation and percussion of the maxillofacial region;

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• During the external examination, it is recommended to assess facial configuration abnormalities, symmetry, soft tissue edema, hematomas, and the condition of the skin, which may present with abrasions, bruises, wounds, soft tissue emphysema, and displacement of the mandibular chin to the side from the midline. These clinical symptoms are necessary to clarify the diagnosis and determine the treatment strategy [3].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: During the oral cavity examination, the state of the oral mucosa and teeth is assessed. Attention is paid to the bite, which is most often disrupted in jaw fractures. When the body of the jaw is fractured, a hematoma is frequently detected in the oral vestibule and on the lingual side of the alveolar part, which is a diagnostic sign, since in soft tissue contusions, a hematoma occurs exclusively on the vestibular side.

Comments: A reliable sign of a jaw fracture within the dental arch is the symptom of mobility of the jaw fragments in the fracture area.

2.3 Laboratory Diagnostics

• Laboratory diagnostic tests are recommended for all patients with soft tissue wounds of the maxillofacial region to determine the severity of the condition (complete blood count, urinalysis, etc.) and to determine the treatment strategy [1, 17, 18].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: soft tissue wounds of the maxillofacial region may be infected with pathogenic microflora.

2.4 Instrumental Diagnostics

• For patients with soft tissue wounds of the maxillofacial region, MSCT is recommended to clarify the diagnosis [17].

Level of Recommendations CEvidence Level 5Level of recommendations C (evidence level - 5).

Comments: in a number of cases, patients with soft tissue wounds of the maxillofacial region may undergo radiography of the entire skull in one or more projections, which makes it possible to rule out fractures of the maxilla, mandible, zygomatic bones, and cranial vault bones. However, radiodiagnosis of multiple facial bone fractures is difficult due to the complex anatomical structure of this region, as well as the blurriness of the bone structures image caused by overlapping details of adjacent skull parts.

2.5 Other Procedures

Internal organ injury

• When internal organ damage is suspected in patients with soft tissue wounds of the maxillofacial region, it is recommended to conduct an appointment (examination, consultation) with a surgeon/pediatric surgeon to determine the treatment strategy and the priority of therapeutic measures [3].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Traumatic Brain Injury

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Wound management

• In patients with soft tissue wounds of the maxillofacial region, it is recommended to perform surgical debridement of facial wounds to achieve optimal treatment outcomes, taking into account functional and aesthetic requirements and following the rules established for facial reconstructive surgery [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• In patients with soft tissue wounds of the maxillofacial region, it is recommended to perform necrectomy in a minimal volume [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: only completely crushed, freely lying, and manifestly non-viable tissue areas are subject to removal. Facial bone fragments should be spared, removing from them only those that have completely lost their connection with the periosteum. Wounds penetrating the oral cavity and wounds with damage to underlying bone structures should be treated starting from the depth of the wound.

• In the presence of facial bone fractures, as a first step, it is recommended to perform osteosynthesis with non-absorbable titanium plates for craniofacial fixation***, followed by layered closure of the open wound (without skin grafting) down to the skin [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• Suturing of the skin and subcutaneous tissue, as well as restoration of facial muscles and tendons, is recommended to be performed in layers [35, 36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: skin edges should be sutured with particular care, bringing them into proper alignment. This is especially important during primary surgical debridement of wounds near natural anatomical orifices: the oral cavity, nose, eyelids, and auricle. In through-and-through wounds of the lips and cheeks communicating with the oral cavity, the wounds must be sutured in layers, separately for the oral mucosa, muscles, and skin. Special attention should be paid to the apposition of wound edges along the border of the vermilion border of the lips, the ciliary margin of the eyelids, and the alae of the nasi.

• For patients with deep bite wounds of the tongue, it is recommended to place horizontal mattress sutures using thick non-absorbable thread, alternating them with interrupted sutures using absorbable suture material [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• In patients with facial skin wounds, it is recommended to place sutures using a fine non-absorbable monofilament on an atraumatic needle for the most aesthetic result [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• Surgical debridement of extensive and multiple wounds or infected tissue of the maxillofacial region is recommended to be performed under combined endotracheal anesthesia [36, 86, 87, 88, 89, 36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: if anesthesia is impossible, local anesthesia—infiltration and/or regional block anesthesia—is used according to indications.

Surgical debridement of a wound or infected tissue is an important procedure that promotes the decontamination of pyogenic flora and mechanical cleansing of the wound; irrigation measures, including the installation of irrigation systems, are carried out using topical medications:

D08A Antiseptics and disinfectants: weak potassium permanganate solution**, chlorhexidine**, hydroxymethylquinoxalinedioxide (adults) – dosing must be carried out in accordance with age restrictions (there is limited data on the safety of hydroxymethylquinoxalinedioxide in children, in particular descriptions of systemic administration of this medicinal product for the treatment of systemic infections in hematology) [87-89, 96-98];

D09A Dressings, which may also be impregnated with antimicrobial agents: nitrofural, chlorhexidine**, povidone-iodine** (adults) – dosing must be carried out in accordance with age restrictions (there is limited data on the safety of povidone-iodine** in children, in particular descriptions of the successful use of this drug in children in otolaryngology during the COVID-19 pandemic) [87-89, 99-100];

D03BA Proteolytic enzymes and B06AA Enzyme preparations: trypsin, chymotrypsin [87-97];

B05BB Solutions affecting the electrolyte balance: sodium chloride** 0.9%. The dosage regimen is determined individually and depends on the volume of affected tissue [87-89].

• A through-and-through wound communicating with the oral cavity is recommended to be isolated by placing a suture on the oral mucosa [3, 35].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: in case of mucosal deficiency, the wound is subsequently managed using turundas. Wounds in the hard palate area are most often managed using iodoform turundas, while small linear wounds or abrasions on the palate can be managed openly.

• Primary closure during facial soft tissue wound debridement is recommended to be performed immediately during primary surgical debridement, preferably no later than 24–36 hours after trauma [1, 5, 36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: in certain cases, with late presentation of the patient, in extensive multiple contused, lacerated, or incised facial wounds – 48 hours and even 72 hours after trauma, mandatory prevention of purulent infection complications (J01) with systemic antibacterial drugs is required.

When suturing wounds in the area of natural orifices, primary closure is applied regardless of the time of patient presentation. For certain types of soft tissue injuries and wound healing conditions, delayed primary suture can be applied on days 3–4. If reparative processes in the wound are favorable, an early secondary suture can be applied after 2–3 weeks. Sutures are removed from the wound upon complete healing in a hospital setting, if necessary under general anesthesia in a child.

• In animal bites to the maxillofacial region, it is recommended to administer a course of rabies vaccinations, injecting antiviral ATC J07 vaccines for rabies prophylaxis, and therefore to such victims according to indications for rabies prophylaxis [36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Indications for the administration of anti-rabies immunoglobulin** and rabies vaccine, its dosage regimen, duration, and other anti-rabies measures are determined by an infectious disease specialist at the anti-rabies clinic during the initial examination, which is available at regional or large city hospitals. If no anti-rabies clinics are available, this care must be provided by a trauma and orthopedic surgeon. These indications are based on a combination of data regarding the epidemiological situation in the region, the nature of the trauma (bite) inflicted by the animal, the anatomical location of the bite (face or extremity), and the epidemiological status (availability of the animal's vaccination record, its vaccination history, etc.). The animal (dog) that inflicted the bites on a child must be isolated and kept under veterinary observation for up to 10 days. To a large extent, administering a full or partial course of the rabies vaccination depends on the behavior and health status of the biting animal.

• For patients with soft tissue defects, it is recommended to use primary plasty during primary surgical debridement (PSD) of wounds to close all wound surfaces and preserve the normal shapes and functions of the damaged area or organ using local tissue flap plasty or autologous skin grafting [15, 36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: The main methods of primary reconstructive surgeries are identified as follows:

- Wound plasty using local tissues;

- Elimination of scar deformity of the maxillofacial region and neck using a vascularized rotational flap;

- Free tissue transplantation: autologous skin grafting, transplantation of free complex grafts, free flap autotransplantation with vascular anastomosis formation;

- Using a part of the traumatized tissue amputated during the injury (according to Krasovitov) to reconstruct facial defects and deformities.

• If it is impossible to close the defect in the early stages following trauma, including when the surgeon/pediatric surgeon lacks the necessary level of training, it is recommended to place muco-cutaneous sutures on the edges of the defect (in the area of the lips, external nose, etc.) [3, 35, 36].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

3.2 Analgesia and sedation

Comments: One of the indications for hospitalization of patients with maxillofacial wounds is the necessity of performing their primary surgical debridement (PSD) under general anesthesia. This constitutes a significant difference in the approach to inpatient care indications for children and adults. In the latter, primary surgical debridement of most skin wounds of the face and oral mucosa can be performed under local anesthesia on an outpatient basis or in the emergency department of a hospital providing maxillofacial surgery care.

3.3 Prevention of Surgical Site Infections

Comments: Currently, the number of relevant studies evaluating the efficacy of various regimens and dosing schedules for SSI prevention in patients (children and adults) with maxillofacial soft tissue wounds is limited. Existing approaches to perioperative antibiotic prophylaxis (PAP) and dosing regimens are based on national methodological guidelines determining the tactics and choice of PAP regimens, studies in populations of patients with maxillofacial fractures, temporomandibular joint surgery, dental implantation, orthognathic surgery, head and neck surgeries, as well as in populations of patients undergoing surgical interventions for pathologies of the oral cavity and maxillofacial region. According to existing data, the following may be recommended: J01CR Combinations of penicillins, including beta-lactamase inhibitors; J01D Other beta-lactam antibacterial drugs; J01FG Lincosamides; J01XA Glycopeptide antibacterials [101–109]

Comments: In the postoperative period, the patient should receive therapeutic doses of drugs in accordance with the instructions for medical use, taking into account the patient's weight, age, and renal and hepatic function. When choosing an antimicrobial therapy regimen, it is recommended to consider the severity of the infectious process, the risk of resistant pathogens, and local microbiological monitoring data. It is advisable to perform a microbiological test for all patients with an "infected" wound.

In institutions providing care for patients with soft tissue wounds of the maxillofacial region, it is advisable to develop local protocols for antimicrobial therapy. As drugs of choice, it is recommended to use [110–116]:

- J01CR ATC – Combinations of penicillins, including beta-lactamase inhibitors

- J01D Other beta-lactam antibacterial drugs

- J01EE Combinations of sulfonamides and trimethoprim, including derivatives

- J01FG Lincosamides

- J01GB Other aminoglycosides

- J01M Quinolone antibacterials

- J01XA Glycopeptide antibacterials

- J01XD Imidazole derivatives

- J01XX Other antibacterials.

3.4 Tetanus prophylaxis

Comments: if the operating surgeon is uncertain about the radical nature of the necrectomy (excision), autologous skin grafting can be performed in a delayed manner on days 2–7.

• For temporary closure of the wound defect after necrectomy, it is recommended to use a skin xenograft and/or other wound dressings that provide an antibacterial effect and create an optimal wound environment [77, 78].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: Prolonged conservative preparation of a granulating wound should be preceded by radical excision of pathological granulations with simultaneous skin grafting.

Other treatment. Physiotherapy

Comments: Ultrasonic treatment of granulating wounds during preparation for surgery provides intensive removal of purulent discharge, fibrin deposits, areas of sloughing scab, necrotic dermis, and pathologically altered hypertrophic granulations.

Comments: the efficacy of other physical methods of local impact on burn wounds requires evidence.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Medical rehabilitation – is a set of therapeutic and preventive measures aimed at preventing and eliminating the pathological consequences of burn trauma [79].

Comments: Rehabilitation programs for patients with maxillofacial wounds encompass a wide range of medical and social measures aimed at the maximum possible restoration of patients' physical and psychological abilities, their successful adaptation in society, and improvement in quality of life.

5. Prevention and Dispensary Observation

Patients discharged from the hospital should be divided into several groups:

- not in need of any treatment;

- those requiring conservative treatment only;

- those requiring relatively urgent surgery due to rapidly progressing pathological changes;

- patients requiring long-term and systematic conservative and surgical treatment due to the large extent of the consequences of burn trauma.

• The main therapeutic and preventive rehabilitation measures for patients with maxillofacial wounds are recommended to be carried out in outpatient settings at polyclinics at the patients' place of residence [73, 75, 79, 86].

Level of Recommendation C (LoR C)Level of evidence - 5.

Comments: after a patient is discharged from the hospital, it is extremely important to clearly organize and continue rehabilitation using various therapeutic and preventive methods aimed at the maximum possible physical and psychosocial recovery of patients. A multidisciplinary team must participate in this work: plastic surgeons, general practitioners/pediatricians, neurologists, physical therapy physicians, medical psychologists, etc.

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

- timeliness of initiation and persistence in carrying out the full range of preventive and therapeutic measures;

- qualification and experience of the medical staff;

- perseverance and discipline of the patients.

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

6. Organization of Medical Care

Indications for emergency hospitalization in the maxillofacial surgery department:

Suspicion of facial bone fracture, including to rule out traumatic brain injury (TBI). Presence of extensive wounds and soft tissue defects of the maxillofacial region in patients.

Indications for planned hospitalization in the Department of Maxillofacial Surgery:

No indications.

Comments: Maxillofacial trauma in children is an emergency condition; all patients with soft tissue trauma and facial bone fractures are recommended for hospitalization on emergency indications. If more than 28 days have passed since the moment of trauma, such a condition does not belong to this group of diseases and is coded according to ICD-10 as T90.2 – Sequelae of skull and facial bone fracture.

Indications for patient discharge from a medical organization

Performance of scheduled diagnostic examinations.

Restoration of anatomical integrity.

No signs of postoperative complications.

7. Additional Information

Negative factors affecting treatment outcomes include:

1) Development of infectious complications.

2) Non-compliance with the regimen of local contact hypothermia.

3) Non-compliance with oral hygiene.

4) Non-compliance by the patient with diet and masticatory activity restrictions.

5) Non-compliance with physical therapy recommendations in the postoperative period.

6) Participation in contact sports within 3 months.

7) Failure to attend follow-up examinations.

8) Non-compliance with other recommendations of the attending physician.

Criteria for Evaluating the Quality of Medical Care

Mechanical injury

References

Appendix A1. Working Group Composition

1. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.

2. Braylovskaya T. V. – MD, Professor, Executive Secretary of the Association of Maxillofacial Surgeons.

3. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

4. Ivanov, S. Yu. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

5. Drobyshev A. Yu. – MD, Professor, Vice-President of the Association of Maxillofacial Surgeons.

6. Yaremenko A. I. – MD, Professor, Vice-President of the Association of Maxillofacial Surgeons.

7. Roginsky, V. V. – MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

8. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".

9. Belchenko V. A. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

10. Topolnitsky, O. Z. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

11. Semenov Mikhail Georgievich – MD, Professor, Head of the Department of Maxillofacial Surgery and Surgical Dentistry named after A. A. Limberg, North-Western State Medical University named after I. I. Mechnikov, Member of the Association of Maxillofacial Surgeons.

12. Durnovo, E. A. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists LLC.

13. Lepilin A. V. – MD, Professor, Board Member of the Association of Maxillofacial Surgeons.

14. Tarasenko S. V. – MD, Professor, Member of the Association of Maxillofacial Surgeons.

15. Epifanov, S. A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1) Maxillofacial surgeons

2) Dentists

3) Orthopedic traumatologists

4) Neurosurgeons

5) Otorhinolaryngologists

6) Neurologists

7) Mid-level medical personnel

8) Healthcare organizers

9) Expert physicians of medical insurance organizations (including for the performance of medical and economic expertise)

10) Medical students, residents, PhD students

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", regarding the development and approval by medical professional non-profit organizations of clinical guidelines (treatment protocols) on the provision of medical care;

2. Order of the Russian Ministry of Health No. 422n dated June 14, 2019, "On approval of the Procedure for providing medical care in the field of 'maxillofacial surgery'";

3. Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010 (as amended on July 3, 2016) "On Compulsory Medical Insurance in النظام Russian Federation";

4. Order of the Russian Ministry of Health No. 203n dated May 10, 2017, «On approval of criteria for assessing the quality of medical care»;

5. Federal Law No. 178-FZ dated July 17, 1999, "On State Social Assistance";

6. Federal Law No. 124-FZ dated July 24, 1998, "On Basic Guarantees of the Rights of the Child in the Russian Federation".

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Childhood traumatism is a serious problem that entails injuries of varying severity, up to life-threatening conditions. The danger increases with age, especially when the child begins to move independently. Various stabbing and cutting tools cause severe injuries to children of all ages when used improperly. As children grow older, the nature of injuries changes: the number of burns decreases, while the number of wounds, contusions, and fractures increases. The main cause of accidents is adult negligence. Maxillofacial trauma leads to severe anatomical, functional, and neurological disorders that may require a number of reconstructive surgeries. As the child grows, the consequences of maxillofacial soft tissue trauma can cause functional and aesthetic disorders of varying degrees and require reconstructive treatment.

When sustaining a maxillofacial injury accompanied by wounds, tissue defects, or loss of consciousness, immediate medical assistance must be sought by calling an ambulance team.

Parents should be aware that visible clinical and radiological recovery upon discharge from the hospital or completion of active outpatient treatment does not rule out the possibility of delayed complications. All children who have suffered maxillofacial trauma must be placed on dispensary follow-up.

First aid for maxillofacial injuries in children

First aid must be provided immediately after the incident. The child must be calmed down. In case of contusion and hematoma in the maxillofacial soft tissues, cold in the form of any item from the refrigerator (a bottle of liquid, a cold product in a package, etc.) wrapped in a clean cloth can be applied to the injury area for 5–10 minutes, and then the procedure can be repeated after 20–30 minutes. The child can be given tablet analgesics in an age-appropriate dosage, and laid down on a bed or sofa. Subsequently, arrangements should be made for a consultation at a healthcare facility.

If there is a skin wound on the face, you can try to treat the wound with a swab soaked in an antiseptic and disinfectant solution, and then apply a light pressure dressing to the face using sterile dressings (bandage); as a last resort, if sterile material is not available, bleeding cessation and a pressure dressing can be performed using clean non-sterile material (bandage, clean towel, bed linen). It is best to seat or lay the child on a bed, sofa, etc.

Adults must stay next to the injured child to provide assistance if necessary in case of vomiting, loss of consciousness, and any inadequate reaction to the situation. Subsequently, it is also necessary to arrange for the transportation of the victim to a healthcare facility using an ambulance or, as a last resort, by self-delivery via personal or public transport.

Timely seeking of specialized medical care will make it possible to utilize all opportunities to save the victim's life and effectively carry out therapeutic and rehabilitation measures.

The patient must be informed about the specific features of treatment and rehabilitation. A necessary prerequisite for their implementation is the patient's informed voluntary consent to the diagnostic and therapeutic measures performed.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.