Features of maxillofacial injuries
The specific nature of facial injuries is due to the anatomical proximity of vital structures: the upper airway, brain, and major blood vessels. This frequently leads to polytrauma requiring emergency care.
Teeth play a special role in injuries. Their presence has a dual significance:
- Positive: by changes in the bite, the physician can quickly diagnose the nature of the fracture, and the teeth themselves serve as reliable support for applying splinting structures.
- Negative: upon impact, teeth turn into secondary missiles. They can act as pathways for infection, and if aspirated into the airways, provoke a lung abscess.
The severity and outcomes of injuries depend on the localization and type of projectile. For example, penetrating shrapnel wounds of the mandible are fatal 2.5 times more often than identical maxillary wounds. However, through-and-through bullet wounds of the maxilla are 7 times more lethal than shrapnel wounds.
All casualties are divided into two equal groups:
- Lightly wounded (about 50%): have isolated soft tissue injuries. Notably, a third of all wounded do not require radical surgical debridement at all.
- Severely wounded (about 50%): patients with injuries to bone structures. They exhibit a high percentage of complications.
Clinical presentation and development of necrosis
In the first hours after injury to the teeth and alveolar process, profuse bleeding, bloody saliva discharge, and acute pain due to tooth pulp damage are observed. It is difficult for the patient to eat, the bite is disrupted, and mobility of bone fragments is noted. In severe destruction, communication may form between the oral cavity, nasal cavity, and maxillary sinus.
It is important to understand that necrotic processes are triggered immediately within the wound tract zone, but during the first 24 hours they proceed covertly and have no external clinical manifestations.
Pathomorphological signs of tissue death manifest in a cascade:
- After 4–6 hours — in muscles and parenchymatous organs.
- After 12–15 hours — in subcutaneous adipose tissue and skin.
- After 2–3 days — in bone tissue.
Delayed complications are often associated with foreign bodies. Tooth fragments that have entered the tissues of the floor of the mouth or tongue may initially not bother the patient, but after a few days inevitably cause the development of phlegmon.
Principles of surgical debridement (PSD)
The basis of treatment is primary surgical debridement (PSD) — the first surgical intervention aimed at cleaning the wound and creating conditions for its healing. If inflammatory complications develop after PSD, secondary surgical debridement is resorted to.
Depending on the timing, PSD is divided into:
- Early: performed within the first 24 hours.
- Delayed: carried out within an interval up to 48 hours.
- Late: carried out after two days.
Modern principles of specialized care require early, single-stage, and comprehensive PSD. At the same time, the approach to facial tissues must be extremely sparing.
A comprehensive approach includes not only the removal of necrotic tissues, but also mandatory fixation of bone fragments, soft tissue defect plastic surgery, and inflow-outflow drainage. In the postoperative period, intensive therapy is critically important to compensate for blood loss and correct the water-electrolyte balance.
Historical experience and statistics
The foundation of modern maxillofacial surgery was laid during the Great Patriotic War. Thanks to the creation of a network of specialized hospitals and the introduction of new methods, doctors achieved unprecedented results.
A huge contribution was made by V.Yu. Kurlyandsky, who developed a functional method of treatment. He scientifically substantiated the use of single-jaw splinting, and introduced therapeutic physical exercises and mechanotherapy for the prevention of temporomandibular joint contracture.
The statistics of return to service during that period are staggering:
- 85.1% of those wounded in the maxillofacial region were completely cured and returned to the front.
- 95.5% of patients with isolated soft tissue wounds of the face successfully completed treatment.
In terms of the absolute number of returned to service, patients with facial injuries ranked first, which had no analogues in world military medicine of that time. With proper organization of care, recovery occurs in 93% of casualties, and only 0.5% of cases end in fatality.
To memorize the timing of necrosis manifestation, use the rule "M-C-B": Muscles (4–6 hours) → Skin (12–15 hours) → Bones (2–3 days). The process goes from soft and richly vascularized tissues to dense ones.
Class and exam questions
Is a gunshot wound always infected?
According to classical military-medical doctrine — yes. However, experimental data show that non-penetrating facial wounds can remain sterile during the first two days.
What is the difference between primary and secondary surgical debridement?
Primary (PSD) is the very first surgical intervention after injury. Secondary is performed only if inflammatory complications have developed in the wound after PSD.
Which jaw injuries are the most dangerous?
Penetrating shrapnel wounds of the mandible are 2.5 times more lethal than analogous injuries of the maxilla. At the same time, through-and-through bullet wounds of the maxilla are 7 times more lethal than shrapnel wounds.
What else to study on this topic
- Gunshot fractures of the zygomatic bone and arch: statistics and polytrauma.
- Organization of care at stages of medical evacuation (MedB, hospitals).
- Functional method of fracture treatment according to V.Yu. Kurlyandsky.
- Intensive therapy in the postoperative period following PSD.
- Mechanisms of lung abscess formation upon tooth aspiration.
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