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Treatment of maxillofacial casualties in the Nigerian civil war
Treatment of maxillofacial casualtiesin the Nigerian civil war M. D. Awty, P.D.S., M.R.C.B., L.R.C.P.,” East Grinstead, England, and P. Banks, M.B., B.S., P.D.S.,*” Cambridge, England Because lack of wounds conflicts. ment of
of transportation difficulties, climatic conditions, psychologic factors, and front-line facilities, the recent civil war in Nigeria produced maxillofacial with problems different from most of those seen in other recent military A review of 225 eases reveals a high rate of success in the delayed treatmajor wounds of the face.
M
odern treatment of gunshot wounds of the face and facial skeleton has evolved from experience gained in the military co&&s of this century.l-ll Although general principles of treatment were laid down during World War I, the advent of antibiotics and other medical advances have greatly facilitated that treatment. The recent civil war in Nigeria produced maxillofacial injuries with problems differing from the majority seen in World War II and in the Korean and Vietnam conflicts. The early Burma campaign of World War II probably offers the closest parallel.123X3 The Nigerian war was fought in a limited jungle enclave, with no special front-line maxillofacial unit, and extreme difficulties were encountered in the transporting of casualties to the single base hospital maxillofacial unit. This contrasts markedly with the special treatment center approach developed in World War IL5 which has reached its ultimate in efficiency in Vietnam.8* lo The peculiar characteristics of casualty management in Nigeria are indicated on the map shown in Fig. 1. The war was fought in the southeast corner of the country, but, because of the total lack of facilities in between, casualties from the three Nigerian divisions had to be brought back to the divisional base areasthe First Division to Kaduna (440 miles), the Second Division to Ibadan (380 miles), and the Third Division to Lagos (a sea journey of 280 miles). Fighting in a tropical rain forest is a difficult military operation, even when backed by the mechanical resources of a country such as the United States. The problems encountered in Nigeria were very different from those of the American forces in Vietnam, as there were no helicopters and initially very few casualty-evacuation air flights were available. All movement in or near the front was on foot or by motor lorry. In the early stages of the war, casualties from the First Division *Consultant **Consultant 4
Oral Surgeon, Queen Victoria Hospital, East &instead, Oral Surgeon, New Addenbrookes Hospital, Cambridge,
Sussex, England. England.
Volume 31 Number 1
Maxillofacial
casuulties
in Nigerian
MAP
civil
OF
war
S
NIGERIA
SHOWING ROUTES USED FOR CLEARANCE Cf MAXILLO-FACIAL CASUALTIES FROM THE BIAFRAN FRONT.
, lol
MILES
Fig. 1. Map showing the divisional deployment of Federal Armed Forces (small arrows) in the latter stages of the Nigerian civil war. The main routes for casualty evacuation are aIso indicated (see text).
were transported by road and those from the Second Division were moved by road and rail, whereas those from the Third Division were subjected to a sea journey before being sorted into the maxillofacial category and put on the train to Kaduna with similar patients from the Second Division. The train journey to the base hospital at Kaduna, where the maxillofacial unit was established, took 24 hours. Kaduna was chosen as the site of the maxillofacial unit because of the availability of ward and theater space as well as the more favorable climate. The area is a high savanna, which is comparatively dry with low humidity, conditions thought to favor healing of soft tissues. During the dry season a hot dry wind (the harmattan) blows over the area, bringing with it a fine dust which permeates everything. The low humidity, coupled with the fine dust, were factors which influenced certain aspects of treatment, particularly the attitude toward tracheostomy. The observations and remarks made here are based on experience with 225
Oral Surg.
6 Awty and Banks
January,
1971
Table 1. Patients treated between December, 1968, and September, 1969 Total number of cases Fractured mandible only Fractured maxilla only Fractured mandible and maxilla Soft-tissue injury only Foreign body without fracture Significant Significant
soft-tissue soft-tissue
involvement loss
225 114 43 34 -:; ioe 3 5 without
fracture
cases of major wounds of the face treated surgically under general anesthesia at Kaduna between December, 1968, and September, 1969 (Table I). CLASSIFICATION OF THE WOUNDS
Previous authors61l4 have adopted a broad classification of maxillofacial gunshot wounds which has proved generally acceptable. In summary, these cases can be considered according to type of missile, direction of impact, or site of injury. In addition, the degree of soft-tissue injury associated with bone damage is of obvious importance in any classification (Table I). An accepted classification is one based on the type of injury : 1. Penetrating 2. Perforating (a) Tangential (b) Transverse 3. Avulsive Wounds of these types can be caused by a variety of missiles, but in general the severe avulsive injuries are associated with large fragments traveling at high velocity. Penetrating injuries are usually the result of low-velocity missiles, whereas high velocity missiles produce perforating injuries characterized by small entry and large exit wounds. One purpose of this article is to draw attention to the problems of late treatment of maxillofacial war wounds and to illustrate how management is influenced by the particular circumstances prevailing in the theater of war concerned. Within the context of the present article, it is thought that certain problems associated with delayed primary treatment deserve special emphasis: 1. A high incidence of general debility on admission to the specialized unit. 2. Limitation of mandibular function resulting from malar/coronoid fibrosis. 3. Frequent mandibular malunion (Fig. 2). 4. Chronic sinuses from sequestra and foreign bodies. 5. Healed malpositioned soft tissue, particularly in the lip and floor of the mouth (Fig. 2). 6. Prolonged exposure of uncovered bone in the mouth in contact with saliva. ‘7. Contracted obstructed nasal airways.
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Number 1
Rig. 2. Typical tissues. This patient
casualties in Nigerian civil war
old maxillofacial wound showing unable to nppose the lips.
healed
malposition
of hard
7
and soft
was
8. The occasional empyema of the lachrymal sac and maxillary sinus. 9. True or false aneurysms of major vessels. TREATMENT
The high proportion of injuries in Nigeria in which effective treatment was delayed invites comparison with historical conflicts, with the obvious difference that the former group had received early antibiotic treatment plus tetanus and gas gangrene prophylactic sera. Certain overriding principles of treatment became established at the Nigerian maxillofacial unit. Re-establishment of effective function was the prime consideration ; esthetic appearance was an important but, of necessity, secondary objective. Because of the generalized reluctance of medical and paramedical personnel to ensure adequate fluid and calo8rie intake in patients with relatively longstanding facial trauma, many patients arrived in a debilitated state. Vigorous general supportive measures were an essential preliminary to any definitive treatment of the actual injury. Kazanjian” and others have emphasized that all gunshot wounds are infected (Fig. 3). In Nigeria the length of time between injury and admission to the maxillofacial unit (Table II) emphasized this problem, and primary treatment
8 Awty and Banks
Oral Surg. January, 1971
Fig. S. A, One-week-old grossly infected gunshot wound dripping pus and saliva. B, Wound after cleaning, showing fragmentation of mandible and soft-tissue loss. C, Same injury 1 month later. An arch bar has been used to bridge the mandibular defect and maintain the fragments in alignment.
was directed toward cleaning the tissues to the stage where effective surgical procedures could be carried out. To this end, an intensive dressing regimen was instituted. Wounds were dressed at least twice and often three times daily. Copious irrigation with warm hydrogen peroxide was followed by selective removal of obviously devitalized tissue and the applieation of Eusol-soaked dressings.* The oral cavity was irrigated with sodium bicarbonate. Local infection often responded better to gauze dressings impregnated with flavine and glycerine, but it was noticed that re-epithelization was less rapid with this than with Eusol soaks. Rarely, wounds were contaminated with yellow phosphorus (Fig. 4), ‘EUSOL (Edinburgh University Solution) : Chlorinated lime and boric acid solution B;‘;; it8 Boric acid, in powder 1215 GL. Chlorinated lime to l,OOO.Oml. Water Prepare as directed in B.P.C. D&n’s solution (chlorinated soda solution, surgical) is similar. It can be used in place of Eusol and would probably be better, because with Dakim’s solution the end product is sodium chloride and not calcium chloride, as with Eusol.
LJfaxillofacial casualties in Nigerians
Volume 31 Number 1
Fig.
civil
war 9
4. Sloughing wound of cheek contaminated by yellow phosphorus.
Fig. 5. Acrylic feeding spoon. The tip can be placed well over the back of the tongue, and the capacity is small enough for a single swallow.
Table
II. Time intervals
from injury
to treatment
Admission within 14 days of injury Admission within 35 days of injury Admission after 6 weeks or more Average time from injury to admission (days) Average time in unit preparing for surgery (days)
117 57 51 9.1 5.1
which produced massive tissue damage, and these were treated with 1 per cent copper sulfate, which converts the phosphorus to harmless insoluble copper phosphide. The absence of bacteriologic control necessitated blanket antibiotic therapy with penicillin and streptomycin. Septicemia, even in the face of rampant local infection, was unknown-a feature, perhaps, of the innate resistance of the Nigerian soldier. Lincomycin was used as a second-line antibiotic when there were clinical indications for a change of regimen.
10
Awty
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Oral Surg. January, 1971
The wounded Nigerian soldier displayed a remarkable capacity to feed himself in spite of severe jaw injury. A simple elongated acrylic spoon (Fig. 5) obviated feeding tubes and gastrostomies in all cases, although some patients arrived after these procedures had been carried out (Fig. 9). Clarkson and associates5 reported four gastrostomies in 1,000 eases of maxillofacial gunshot wounds. The same authors commented that their total of twenty-seven tracheostomies (2.7 per cent) was small and that probably too few were performed in the forward area. In the hot, very dry, and dusty climate of northern Nigeria, tracheostomy was a positive hazard with the resources available. Apart from the climate, the impossibility of aseptic maintenance and the racial tendency to tracheal stenosis increased the dangers of the procedure. In the first year at the maxillofacial unit, four tracheostomies were performed of necessity (that is, in 1.6 per cent of all cases), and two of these were performed to meet emergencies created by stenosis of healed tracheostomies performed 1 year previously at the war front, In fact, tracheostomies were rarely performed at the front, and many patients with severe injuries survived without them (Figs. 6 and 9). Even after
Fig. 6. A, Extensive bomb blast wound of face. There was complete mandibular bone loss from the lower first molars. B, Same patient at end of surgical procedure. The bone fragments were maintained in anatomic relationship bv arch bars, but intermaxillary fixation was d&3@ for several days. The liberal dependent drainage is illustrated. C, Same patient 1 month later. Even at this stage, in spite of obvious soft-tissue loss, there is a competent oral sphincter.
Maxillofacial
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casualties in Nigerian civil war
11
prolonged surgical procedures, such as that shown in Fig. 6, B, with attendant embarrassment to the airway, careful postoperative nursing with the patient in the cardiac position made it possible to avoid tracheostomy. Definitive treatment of the Nigerian maxillofacial casualties can be considered in categories which were particularly relevant to this war. Old
injuries
Twenty-two per cent of all patients arrived at the maxillofacial unit 6 weeks or more after injury, and certain common problems arose. The penetrating injury involving the malar/coronoid process (Fig. 4) produced fibrous or bony ankylosis. These casesoften required extensive surgical exploration with removal of bone fragments before the mandible could be mobilized. Postoperatively, vigorous physiotherapy under supervision with a simple screw exerciser was all that the available resources permitted, but it prevented permanent limitation of function in all cases. Malunion was treated by refracture where necessary. Healed malposition of soft tissues (Fig. 2) was managed by meticulous surgical freeing of mucosa and skin and repositioning, often assisted by full-thickness rotated or transposed flaps. Epithelization had often increased the available skin and mucosa, permitting defects to be closed more easily with local tissue. Infected
jaw/facial
bone
fractures
Only two patients reached the maxillofacial unit within 24 hours following injury, and 25 per cent arrived between 14 and 35 days following injury ; thus, infected fractures were the rule (Table II). After initial dressing preparation, these patients were taken to the operating theater as soon as possible. Table III summarizes the main theme of treatment. Cast-metal splints played little part in the management of even extensively comminuted jaw fractures. Detailed preoperative planning was usually impossible, as the number of teeth that would have to be sacrificed was indeterminate prior to examination of the patient under anesthesia. Many teeth were fractured below the gingival margin without anatomic displacement creating a constant problem. The dangers of retention of teeth in the fracture area cannot be underestimated, and gross dissolution of bone can occur (Fig. 7). In general, elimination of infection within a sleeve of healthy periosteum provides the most favorable Table
Ill.
Treatment of fractures No treatment Removal of bullet or foreien bodv Antral packing and/or antiostom”y DBbridement and/or removal of teeth Drainage of fracture site Fixation: Eyelet wires Arch bars Splints Transosseous wires Pins Plates Internal suspension Extraoral c.m.f.
17 119 110
12 Awty and Banks
Oral Surg. January, 1971
A
B
c
Fig. 7.
woutnd. B, &ii
wer e retain .3d and draiaa .ge, ling.
[arch 28, lQ69. Comminuted fracture of mandible as a ra 3u1t of a bullet 5, 1969. Extreme example of dissolution of bone around infe cted ?th which ;~ally to maintain bone contour. C, July 10, 1989. Following toot h”: ixtr action lne regeneration has begun. Secondary infedtion has consi dera.blg. delayed
Volume Number
31 I
Maxillofacial
Fig. 8. Large mandibular defect is bolted to the mandibular remnant.
temporarily
casualties in NigeriaTa civil war
bridged
by Vitallium
13
bar. Note that the bar
environment for osseous regeneration. If this is achieved, absolutely rigid fixation is not essential. Nevertheless, most fractures demanded initial retention of teeth to maintain any semblance of bony contour and stability. After initial stabilization with arch bars, teeth were selectively removed as it became necessary to control and eliminate sepsis. Interosseous wiring to reconstitute the mandible from bony fragments, as recommended by Morgan and Szmyd; may succeed if drainage is adequate. Drains were used in 50 per cent of the cases and were, in the main, through-and-through initially. This permitted regular postoperative irrigation with saline solution or, in grossly infected cases, hydrogen peroxide, for up to 1 week, and the drain was then shortened to allow the intraoral wound to close. No salivary fistulas developed, and drainage was maintained as long as a clinical indication remained. Where a bony defect existed, the fragments were maintained in correct anatomic position by means of arch bars, splints, or metal implants (Fig. 8). Infected penetrating wounds of the antrum were drained via nasal antrostomies. An oral opening, if present, was closed primarily by local flaps if necessary. It was often useful to eliminate dead space by packing the antral remnants with gauze impregnated with Whitehead’s varnish.* *Compound paint of iodoform, B.P.C. 1954 (Whitehead’s varnish) : 1. Benzoin Sumatra, 100 Gm.; 2. Prepared Storax, 75 Gm.; 3. Balsam of Tolu, 50 Gm.; 4. Iodoform, 100 Gm.; 5. Solvent Ether, to 1,000 ml. Ingredients 1, 2, and 3 are macerated with 800 ml. of solvent ether and allowed to stand for 1 week, shaking frequently. The clear solution is decanted, the iodoform is dissolved in it, and the solution is made up to 1 liter.
14
Awty
and Banks
A
Oral Burg. January, 1971
C
Fig. 9. A, Condition on arrival at maxillofacial unit 8 days after injury. B, Three days later, after surgical repair. Loss of lip tissue necessitated the use of local full-thickness flaps and a mucosal advance to establish an oral opening of adequate size. C, Same patient 10 days later.
Treatment
of soft
tissues
The casualties in this maxillofacial unit (Table I) were marked by a high proportion of cases with extensive soft-tissue injury (38 per cent) or soft-tissue loss (22.2 per cent). It has been noted that in Nigeria special consideration determined attitudes toward soft-tissue loss. The men were often psychologically illsuited to multistage surgical treatment, and function took precedence over esthetics. Skin-to-mucosa suturing has often been advocated in casesof extensive tissue loss, but this often results, after contraction, in reducing the available local tissue. Extensive local flaps were often used at the first surgical assay with more rewarding conservation of tissue (Fig. 9). Primary closure within 36 hours was
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15
Pig. 9 (cont’d). D, Radiographic appearance on admission to unit. The patient had survived 8 days without tracheostomy, in spite of extensive soft-tissue damage and this degree of displacement of the mandibular symphysis. E, Symphysis repositioned by transosseous wires and drained. Bony union occurred in 7 weeks.
possible in defined by wounds in debridement ment of lip Reconstructive
only one case. Late primary suturing within 2 weeks of arrival, as Kazanjian3 was invariably successful after initial cleaning of the the ward for an average of 5 days followed by thorough surgical under general anesthesia. Great attention was paid to the attainseal, one yardstick of successful functional jaw surgery. procedures
In a few cases an unacceptable soft-tissue defect remained after late primary suturing. In facing the problem of reconstruction, a one-stage local flap which achieved an acceptable functional result was preferred to pedicle reconstruction which, in other geographical areas, would have been the method of choice. Selected eases were managed by means of tube pedicles or facial prostheses. Residual mandibular defects, particularly at the symphysis, presented a major problem in this war (Fig. 8). The relative avascularity of the mandible, coupled with the enormous difficulty of maintaining an aseptic environment, reduced the bone graft success rate to only 50 per cent, even after immobilization for up to 6 months. Most of the bone grafts required were 5 em. or more in length, which added to the difficulty. Thus, primary bony continuity became a surgical objective which outweighed all else after actual survival had been assured. Complications
The extensive tissue destruction caused by missile injuries produced considerable scarring, and limitation of mandibular movement was a common
16
Awty
and Banks
Oral Surg. January, 1971
problem after bony healing. Intensive physiotherapy under supervision was the solution to this problem. Late sequestration and re-infection of fracture sites occurred when teeth were, perforce, initially retained in the fracture area or when tissue drains were inadequate or were removed too early. This complication became less common as surgical experience increased. The major late complications experienced in this unit were tetanus (one case), meningitis (one case), and secondary hemorrhage (two cases). Kazanjian3 notes that secondary hemorrhage is the most dreaded complication, particularly from wounds of the base of the tongue and pharynx. Very few cases occurred in this unit, but the only death recorded in the first year was due to secondary hemorrhage. Because of the risk of secondary hemorrhage, it became surgical policy to remove all foreign bodies retained in the tissues, if practicable. Apart from the surgical risk, it was found that, for psychologic reasons, few Nigerian soldiers could be returned to duty if they were aware of the fact that a bullet was retained in the tissues. DISCUSSION This article has emphasized the problem of infected compound fractures of the jaws and has shown how intensive general and local care can lead to a high success rate. Morgan and Szmyd,Q in a report on thirty-one patients with extensive comminuted fractures of the mandible evacuated from Vietnam to the Philippines, noted that the wounds were all infected despite broad-spectrum antibiotics. They comment that, of 181 deaths in their military hospital, a high proportion were from septicemia-a condition most uncommon in the milit.ary hospital at Kaduna and unknown in the maxillofacial unit. This fact may be associated with innate or acquired racial resistance. In contrast to other views expressed,15 it was found that suture lines around the mouth and general patient morale benefited from establishment of oral feeding at an early stage. It was found that this policy did not increase the incidence of postoperative infection. For reasons outlined above, tracheostomies were avoided where possible. Although one cannot know how many deaths resulted from lack of tracheostomy at the front line, it was possible to compare results from two war fronts-one in the north with good front-to-base hospital communications and one in the south with very poor communications. No observable difference in the survival of patients with very severe facial injuries was apparent. It is probable that the attendant head injury common in the major civilian maxillofacial injuries which result from road traffic trauma constitutes the main indication for tracheostomy. In Vietnam, tracheostomy figures for facial injuries vary from 14.3 per centI to 17 per cent.lO The morbidity cannot be underestimated, and many of these patients would not have had tracheostomies in Nigeria (Figs. 6 and 9). Pennl’ reports that the Israeli Medical Corps’ policy is to replace emergency tracheostomy by intubation were possible, as casualties are then easier to transport and bleeding wounds of the throat and neck can be packed. McIndoe2 states that eyelet wiring fails as a method of fixation for severe injuries and that the use of cast-metal splints is the method of choice. In this
Volume Number
31 1
Maxillofacial
casualties in Nigerian
civil war
17
war experience with wiring techniques has shown that adequate fixation is achieved. The difficulties of preoperative planning have been emphasized, and in this context preliminary impressions were found to be impractical and useless. The most important factor in attaining union of jaw fractures is elimination of infection by adequate debridement and drainage. It was not fonnd that drainage delays healing of even nonsuppurating fractures, a view stated by Clarkson and associates.5 In fact, even when patients with 3- or 4-week-old infected mandibular fractures arrived at the unit with no semblance of healing, the regimen of cleaning, debridement, fixation, and drainage produced the same rate of healing as in patients seen within a few days of injury. It is remarkable that prolonged exposure of bone bathed in saliva is compatible with survival of the fragment. No mandibular fracture without a bone gap failed to unite, and many with bone gaps at initial examination (12.5 per cent) proceeded to union in continuity. In the latter group, use of all available healthy bone fragments, as advocated by Kwapis,6 contributed to success. Metal implants were used in a few cases to maintain the anatomic relationship of fragments. It was found that these were of only temporary use because of mechanical failure or infection. Such implants must be fixed by bolts rather than screws (Fig. 8). The concept of late primary closure of infected soft-tissue wounds is important.3 Primary suturing of gunshot wounds at the front was usually followed by complete breakdown, and it is better to pack such wounds open until they can be cleaned. Where there was tissue loss, it was found that good functional results could be obtained in most casesby the use of local tissue flaps at an early stage, and much extensive late reconstruction was avoided. Bone loss at the symphysis of the mandible is a much bigger problem than lateral loss in the body or ramus. In the latter group, excellent function is often achieved without resorting to bone grafts. It is important to realize that the length of time required for a bone graft to succeed is proportional to the length of the graft.5 Fatalities at this maxillofacial unit were very low. The only death was caused by massive secondary hemorrhage related to an apparently trivial penetrating injury in which a small shell fragment in the neck eventually resulted in complete erosion of the common carotid and jugular vein. It should be noted that of thirty-three deaths recorded by Clarkson and colleagues,5most were secondary to associated brain or brain-stem injury. In this war such patients could not survive long enough to reach the base hospital. The fact that many patients with massive jaw injuries survived for so long is a tribute to the ability of the Nigerian surgeons at the war front in ensuring that blood transfusion, antibiotic therapy, and tetanus and gas gangrene prophylactic regimens were always instituted in the most difficult of circumstances. This maxillofacial unit was established in 1968 by the Federal Nigerian Armed Forces Medical Service, the Institute of Health of Ahmadu Bello University, and the British Ministry of Overseas Development, as the result of a survey and report by Mr. T. G. Ward. We would particularly like to acknowledge the help received in the treatment of patients from Lieutenant Colonel Sho Silva and his colleagues of the Federal Armed Forces Medical Service and from Dr. R. I. Shamia.
18
Awty
and Banks
Oral January,
Burg. 1971
REFERENCES 1. Gillies, H. D.: Discussion on Surgical and Dental Treatment of Severe Facial Injuries, Trans. Med. Sot. London 41: 165, 1918. 2. McIndoe, A. H.: Surgical and Dental Treatment of Fractures of the Upper and Lower Jaws in War Time, Proc. Roy. Sot. Med. 84: 267, 1941. 3. Kazanjian, V. H.: An Outline of the Treatment of Extensive Comminuted Fractures of the Mandible, Amer. J. Orthodont. & Oral Surg. 28: 265, 1942. 4. Kazanjian, V. H.: Early Treatment of Gunshot Wounds of the Face and Jaws, Surgery 15: 22, 1944. 5. Clarkson,.P., Wilson, T. H. H., and Lawrie, R. S.: Treatment of Jaw and Face Casualties in the British Army, Ann. Surg. 123: 190, 1946. 6. Kwapis, B. W.: Early Management of Maxillo-facial War Injuries, J. Oral Surg. 12: 293, 1954. 7. Ben-Hur, N., Neuman, Z., and Snyderman, R.: Plastic Surgery in the Six Day War in Jerusalem, Plast. Reconstr. Burg. 41: 333, 1968. 8. Andrew, J. L.: Maxillo-facial Trauma in Vietnam, J. Oral Surg. 26: 457, 1968. 9. Morgan, H. H., and Szmyd, L.: Maxillo-facial War Injuries, J. Oral Surg. 26: 727, 1968. 10. Terry, B. C.: Facial Injuries in Military Combat: Definitive Care, J. Oral Surg. 27: 551, 1969. 11. Tinder, L. E., Osbon, D. B., Lilly, G. E., Salem, J. E., and Cutcher, J. L.: Maxillo-facial Injuries Sustained in the Vietnam Conflict, Milit. Med. 134: 668, 1969. 12. Hovell, J.: Personal communication, 1970. 13. Watson, J.: Personal communication, 1970. 14. Osbon, D. B.: Early Treatment of Soft Tissue Injuries of the Face, J. Oral Surg. 27: 480, 1969. 15. Irby, W. B.: Facial Injuries in Military Combat-Intermediate Care, J. Oral Burg. 27: 548, 1969. 16. Penn, J.: The Third Israeli-Arab War: June, 1967, Mediese Bydraes. 13: 396, 1967. Reprint requests to : M. D. Awty, F.D.S., M.R.C.S., Queen Victoria Hospital East Grinstead Sussex, United Kingdom
L.R.C.P.
of transportation difficulties, climatic conditions, psychologic factors, and front-line facilities, the recent civil war in Nigeria produced maxillofacial with problems different from most of those seen in other recent military A review of 225 eases reveals a high rate of success in the delayed treatmajor wounds of the face.
M
odern treatment of gunshot wounds of the face and facial skeleton has evolved from experience gained in the military co&&s of this century.l-ll Although general principles of treatment were laid down during World War I, the advent of antibiotics and other medical advances have greatly facilitated that treatment. The recent civil war in Nigeria produced maxillofacial injuries with problems differing from the majority seen in World War II and in the Korean and Vietnam conflicts. The early Burma campaign of World War II probably offers the closest parallel.123X3 The Nigerian war was fought in a limited jungle enclave, with no special front-line maxillofacial unit, and extreme difficulties were encountered in the transporting of casualties to the single base hospital maxillofacial unit. This contrasts markedly with the special treatment center approach developed in World War IL5 which has reached its ultimate in efficiency in Vietnam.8* lo The peculiar characteristics of casualty management in Nigeria are indicated on the map shown in Fig. 1. The war was fought in the southeast corner of the country, but, because of the total lack of facilities in between, casualties from the three Nigerian divisions had to be brought back to the divisional base areasthe First Division to Kaduna (440 miles), the Second Division to Ibadan (380 miles), and the Third Division to Lagos (a sea journey of 280 miles). Fighting in a tropical rain forest is a difficult military operation, even when backed by the mechanical resources of a country such as the United States. The problems encountered in Nigeria were very different from those of the American forces in Vietnam, as there were no helicopters and initially very few casualty-evacuation air flights were available. All movement in or near the front was on foot or by motor lorry. In the early stages of the war, casualties from the First Division *Consultant **Consultant 4
Oral Surgeon, Queen Victoria Hospital, East &instead, Oral Surgeon, New Addenbrookes Hospital, Cambridge,
Sussex, England. England.
Volume 31 Number 1
Maxillofacial
casuulties
in Nigerian
MAP
civil
OF
war
S
NIGERIA
SHOWING ROUTES USED FOR CLEARANCE Cf MAXILLO-FACIAL CASUALTIES FROM THE BIAFRAN FRONT.
, lol
MILES
Fig. 1. Map showing the divisional deployment of Federal Armed Forces (small arrows) in the latter stages of the Nigerian civil war. The main routes for casualty evacuation are aIso indicated (see text).
were transported by road and those from the Second Division were moved by road and rail, whereas those from the Third Division were subjected to a sea journey before being sorted into the maxillofacial category and put on the train to Kaduna with similar patients from the Second Division. The train journey to the base hospital at Kaduna, where the maxillofacial unit was established, took 24 hours. Kaduna was chosen as the site of the maxillofacial unit because of the availability of ward and theater space as well as the more favorable climate. The area is a high savanna, which is comparatively dry with low humidity, conditions thought to favor healing of soft tissues. During the dry season a hot dry wind (the harmattan) blows over the area, bringing with it a fine dust which permeates everything. The low humidity, coupled with the fine dust, were factors which influenced certain aspects of treatment, particularly the attitude toward tracheostomy. The observations and remarks made here are based on experience with 225
Oral Surg.
6 Awty and Banks
January,
1971
Table 1. Patients treated between December, 1968, and September, 1969 Total number of cases Fractured mandible only Fractured maxilla only Fractured mandible and maxilla Soft-tissue injury only Foreign body without fracture Significant Significant
soft-tissue soft-tissue
involvement loss
225 114 43 34 -:; ioe 3 5 without
fracture
cases of major wounds of the face treated surgically under general anesthesia at Kaduna between December, 1968, and September, 1969 (Table I). CLASSIFICATION OF THE WOUNDS
Previous authors61l4 have adopted a broad classification of maxillofacial gunshot wounds which has proved generally acceptable. In summary, these cases can be considered according to type of missile, direction of impact, or site of injury. In addition, the degree of soft-tissue injury associated with bone damage is of obvious importance in any classification (Table I). An accepted classification is one based on the type of injury : 1. Penetrating 2. Perforating (a) Tangential (b) Transverse 3. Avulsive Wounds of these types can be caused by a variety of missiles, but in general the severe avulsive injuries are associated with large fragments traveling at high velocity. Penetrating injuries are usually the result of low-velocity missiles, whereas high velocity missiles produce perforating injuries characterized by small entry and large exit wounds. One purpose of this article is to draw attention to the problems of late treatment of maxillofacial war wounds and to illustrate how management is influenced by the particular circumstances prevailing in the theater of war concerned. Within the context of the present article, it is thought that certain problems associated with delayed primary treatment deserve special emphasis: 1. A high incidence of general debility on admission to the specialized unit. 2. Limitation of mandibular function resulting from malar/coronoid fibrosis. 3. Frequent mandibular malunion (Fig. 2). 4. Chronic sinuses from sequestra and foreign bodies. 5. Healed malpositioned soft tissue, particularly in the lip and floor of the mouth (Fig. 2). 6. Prolonged exposure of uncovered bone in the mouth in contact with saliva. ‘7. Contracted obstructed nasal airways.
Volume
Maxillofacial
31
Number 1
Rig. 2. Typical tissues. This patient
casualties in Nigerian civil war
old maxillofacial wound showing unable to nppose the lips.
healed
malposition
of hard
7
and soft
was
8. The occasional empyema of the lachrymal sac and maxillary sinus. 9. True or false aneurysms of major vessels. TREATMENT
The high proportion of injuries in Nigeria in which effective treatment was delayed invites comparison with historical conflicts, with the obvious difference that the former group had received early antibiotic treatment plus tetanus and gas gangrene prophylactic sera. Certain overriding principles of treatment became established at the Nigerian maxillofacial unit. Re-establishment of effective function was the prime consideration ; esthetic appearance was an important but, of necessity, secondary objective. Because of the generalized reluctance of medical and paramedical personnel to ensure adequate fluid and calo8rie intake in patients with relatively longstanding facial trauma, many patients arrived in a debilitated state. Vigorous general supportive measures were an essential preliminary to any definitive treatment of the actual injury. Kazanjian” and others have emphasized that all gunshot wounds are infected (Fig. 3). In Nigeria the length of time between injury and admission to the maxillofacial unit (Table II) emphasized this problem, and primary treatment
8 Awty and Banks
Oral Surg. January, 1971
Fig. S. A, One-week-old grossly infected gunshot wound dripping pus and saliva. B, Wound after cleaning, showing fragmentation of mandible and soft-tissue loss. C, Same injury 1 month later. An arch bar has been used to bridge the mandibular defect and maintain the fragments in alignment.
was directed toward cleaning the tissues to the stage where effective surgical procedures could be carried out. To this end, an intensive dressing regimen was instituted. Wounds were dressed at least twice and often three times daily. Copious irrigation with warm hydrogen peroxide was followed by selective removal of obviously devitalized tissue and the applieation of Eusol-soaked dressings.* The oral cavity was irrigated with sodium bicarbonate. Local infection often responded better to gauze dressings impregnated with flavine and glycerine, but it was noticed that re-epithelization was less rapid with this than with Eusol soaks. Rarely, wounds were contaminated with yellow phosphorus (Fig. 4), ‘EUSOL (Edinburgh University Solution) : Chlorinated lime and boric acid solution B;‘;; it8 Boric acid, in powder 1215 GL. Chlorinated lime to l,OOO.Oml. Water Prepare as directed in B.P.C. D&n’s solution (chlorinated soda solution, surgical) is similar. It can be used in place of Eusol and would probably be better, because with Dakim’s solution the end product is sodium chloride and not calcium chloride, as with Eusol.
LJfaxillofacial casualties in Nigerians
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Fig.
civil
war 9
4. Sloughing wound of cheek contaminated by yellow phosphorus.
Fig. 5. Acrylic feeding spoon. The tip can be placed well over the back of the tongue, and the capacity is small enough for a single swallow.
Table
II. Time intervals
from injury
to treatment
Admission within 14 days of injury Admission within 35 days of injury Admission after 6 weeks or more Average time from injury to admission (days) Average time in unit preparing for surgery (days)
117 57 51 9.1 5.1
which produced massive tissue damage, and these were treated with 1 per cent copper sulfate, which converts the phosphorus to harmless insoluble copper phosphide. The absence of bacteriologic control necessitated blanket antibiotic therapy with penicillin and streptomycin. Septicemia, even in the face of rampant local infection, was unknown-a feature, perhaps, of the innate resistance of the Nigerian soldier. Lincomycin was used as a second-line antibiotic when there were clinical indications for a change of regimen.
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The wounded Nigerian soldier displayed a remarkable capacity to feed himself in spite of severe jaw injury. A simple elongated acrylic spoon (Fig. 5) obviated feeding tubes and gastrostomies in all cases, although some patients arrived after these procedures had been carried out (Fig. 9). Clarkson and associates5 reported four gastrostomies in 1,000 eases of maxillofacial gunshot wounds. The same authors commented that their total of twenty-seven tracheostomies (2.7 per cent) was small and that probably too few were performed in the forward area. In the hot, very dry, and dusty climate of northern Nigeria, tracheostomy was a positive hazard with the resources available. Apart from the climate, the impossibility of aseptic maintenance and the racial tendency to tracheal stenosis increased the dangers of the procedure. In the first year at the maxillofacial unit, four tracheostomies were performed of necessity (that is, in 1.6 per cent of all cases), and two of these were performed to meet emergencies created by stenosis of healed tracheostomies performed 1 year previously at the war front, In fact, tracheostomies were rarely performed at the front, and many patients with severe injuries survived without them (Figs. 6 and 9). Even after
Fig. 6. A, Extensive bomb blast wound of face. There was complete mandibular bone loss from the lower first molars. B, Same patient at end of surgical procedure. The bone fragments were maintained in anatomic relationship bv arch bars, but intermaxillary fixation was d&3@ for several days. The liberal dependent drainage is illustrated. C, Same patient 1 month later. Even at this stage, in spite of obvious soft-tissue loss, there is a competent oral sphincter.
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11
prolonged surgical procedures, such as that shown in Fig. 6, B, with attendant embarrassment to the airway, careful postoperative nursing with the patient in the cardiac position made it possible to avoid tracheostomy. Definitive treatment of the Nigerian maxillofacial casualties can be considered in categories which were particularly relevant to this war. Old
injuries
Twenty-two per cent of all patients arrived at the maxillofacial unit 6 weeks or more after injury, and certain common problems arose. The penetrating injury involving the malar/coronoid process (Fig. 4) produced fibrous or bony ankylosis. These casesoften required extensive surgical exploration with removal of bone fragments before the mandible could be mobilized. Postoperatively, vigorous physiotherapy under supervision with a simple screw exerciser was all that the available resources permitted, but it prevented permanent limitation of function in all cases. Malunion was treated by refracture where necessary. Healed malposition of soft tissues (Fig. 2) was managed by meticulous surgical freeing of mucosa and skin and repositioning, often assisted by full-thickness rotated or transposed flaps. Epithelization had often increased the available skin and mucosa, permitting defects to be closed more easily with local tissue. Infected
jaw/facial
bone
fractures
Only two patients reached the maxillofacial unit within 24 hours following injury, and 25 per cent arrived between 14 and 35 days following injury ; thus, infected fractures were the rule (Table II). After initial dressing preparation, these patients were taken to the operating theater as soon as possible. Table III summarizes the main theme of treatment. Cast-metal splints played little part in the management of even extensively comminuted jaw fractures. Detailed preoperative planning was usually impossible, as the number of teeth that would have to be sacrificed was indeterminate prior to examination of the patient under anesthesia. Many teeth were fractured below the gingival margin without anatomic displacement creating a constant problem. The dangers of retention of teeth in the fracture area cannot be underestimated, and gross dissolution of bone can occur (Fig. 7). In general, elimination of infection within a sleeve of healthy periosteum provides the most favorable Table
Ill.
Treatment of fractures No treatment Removal of bullet or foreien bodv Antral packing and/or antiostom”y DBbridement and/or removal of teeth Drainage of fracture site Fixation: Eyelet wires Arch bars Splints Transosseous wires Pins Plates Internal suspension Extraoral c.m.f.
17 119 110
12 Awty and Banks
Oral Surg. January, 1971
A
B
c
Fig. 7.
woutnd. B, &ii
wer e retain .3d and draiaa .ge, ling.
[arch 28, lQ69. Comminuted fracture of mandible as a ra 3u1t of a bullet 5, 1969. Extreme example of dissolution of bone around infe cted ?th which ;~ally to maintain bone contour. C, July 10, 1989. Following toot h”: ixtr action lne regeneration has begun. Secondary infedtion has consi dera.blg. delayed
Volume Number
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Maxillofacial
Fig. 8. Large mandibular defect is bolted to the mandibular remnant.
temporarily
casualties in NigeriaTa civil war
bridged
by Vitallium
13
bar. Note that the bar
environment for osseous regeneration. If this is achieved, absolutely rigid fixation is not essential. Nevertheless, most fractures demanded initial retention of teeth to maintain any semblance of bony contour and stability. After initial stabilization with arch bars, teeth were selectively removed as it became necessary to control and eliminate sepsis. Interosseous wiring to reconstitute the mandible from bony fragments, as recommended by Morgan and Szmyd; may succeed if drainage is adequate. Drains were used in 50 per cent of the cases and were, in the main, through-and-through initially. This permitted regular postoperative irrigation with saline solution or, in grossly infected cases, hydrogen peroxide, for up to 1 week, and the drain was then shortened to allow the intraoral wound to close. No salivary fistulas developed, and drainage was maintained as long as a clinical indication remained. Where a bony defect existed, the fragments were maintained in correct anatomic position by means of arch bars, splints, or metal implants (Fig. 8). Infected penetrating wounds of the antrum were drained via nasal antrostomies. An oral opening, if present, was closed primarily by local flaps if necessary. It was often useful to eliminate dead space by packing the antral remnants with gauze impregnated with Whitehead’s varnish.* *Compound paint of iodoform, B.P.C. 1954 (Whitehead’s varnish) : 1. Benzoin Sumatra, 100 Gm.; 2. Prepared Storax, 75 Gm.; 3. Balsam of Tolu, 50 Gm.; 4. Iodoform, 100 Gm.; 5. Solvent Ether, to 1,000 ml. Ingredients 1, 2, and 3 are macerated with 800 ml. of solvent ether and allowed to stand for 1 week, shaking frequently. The clear solution is decanted, the iodoform is dissolved in it, and the solution is made up to 1 liter.
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Oral Burg. January, 1971
C
Fig. 9. A, Condition on arrival at maxillofacial unit 8 days after injury. B, Three days later, after surgical repair. Loss of lip tissue necessitated the use of local full-thickness flaps and a mucosal advance to establish an oral opening of adequate size. C, Same patient 10 days later.
Treatment
of soft
tissues
The casualties in this maxillofacial unit (Table I) were marked by a high proportion of cases with extensive soft-tissue injury (38 per cent) or soft-tissue loss (22.2 per cent). It has been noted that in Nigeria special consideration determined attitudes toward soft-tissue loss. The men were often psychologically illsuited to multistage surgical treatment, and function took precedence over esthetics. Skin-to-mucosa suturing has often been advocated in casesof extensive tissue loss, but this often results, after contraction, in reducing the available local tissue. Extensive local flaps were often used at the first surgical assay with more rewarding conservation of tissue (Fig. 9). Primary closure within 36 hours was
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Pig. 9 (cont’d). D, Radiographic appearance on admission to unit. The patient had survived 8 days without tracheostomy, in spite of extensive soft-tissue damage and this degree of displacement of the mandibular symphysis. E, Symphysis repositioned by transosseous wires and drained. Bony union occurred in 7 weeks.
possible in defined by wounds in debridement ment of lip Reconstructive
only one case. Late primary suturing within 2 weeks of arrival, as Kazanjian3 was invariably successful after initial cleaning of the the ward for an average of 5 days followed by thorough surgical under general anesthesia. Great attention was paid to the attainseal, one yardstick of successful functional jaw surgery. procedures
In a few cases an unacceptable soft-tissue defect remained after late primary suturing. In facing the problem of reconstruction, a one-stage local flap which achieved an acceptable functional result was preferred to pedicle reconstruction which, in other geographical areas, would have been the method of choice. Selected eases were managed by means of tube pedicles or facial prostheses. Residual mandibular defects, particularly at the symphysis, presented a major problem in this war (Fig. 8). The relative avascularity of the mandible, coupled with the enormous difficulty of maintaining an aseptic environment, reduced the bone graft success rate to only 50 per cent, even after immobilization for up to 6 months. Most of the bone grafts required were 5 em. or more in length, which added to the difficulty. Thus, primary bony continuity became a surgical objective which outweighed all else after actual survival had been assured. Complications
The extensive tissue destruction caused by missile injuries produced considerable scarring, and limitation of mandibular movement was a common
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Awty
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problem after bony healing. Intensive physiotherapy under supervision was the solution to this problem. Late sequestration and re-infection of fracture sites occurred when teeth were, perforce, initially retained in the fracture area or when tissue drains were inadequate or were removed too early. This complication became less common as surgical experience increased. The major late complications experienced in this unit were tetanus (one case), meningitis (one case), and secondary hemorrhage (two cases). Kazanjian3 notes that secondary hemorrhage is the most dreaded complication, particularly from wounds of the base of the tongue and pharynx. Very few cases occurred in this unit, but the only death recorded in the first year was due to secondary hemorrhage. Because of the risk of secondary hemorrhage, it became surgical policy to remove all foreign bodies retained in the tissues, if practicable. Apart from the surgical risk, it was found that, for psychologic reasons, few Nigerian soldiers could be returned to duty if they were aware of the fact that a bullet was retained in the tissues. DISCUSSION This article has emphasized the problem of infected compound fractures of the jaws and has shown how intensive general and local care can lead to a high success rate. Morgan and Szmyd,Q in a report on thirty-one patients with extensive comminuted fractures of the mandible evacuated from Vietnam to the Philippines, noted that the wounds were all infected despite broad-spectrum antibiotics. They comment that, of 181 deaths in their military hospital, a high proportion were from septicemia-a condition most uncommon in the milit.ary hospital at Kaduna and unknown in the maxillofacial unit. This fact may be associated with innate or acquired racial resistance. In contrast to other views expressed,15 it was found that suture lines around the mouth and general patient morale benefited from establishment of oral feeding at an early stage. It was found that this policy did not increase the incidence of postoperative infection. For reasons outlined above, tracheostomies were avoided where possible. Although one cannot know how many deaths resulted from lack of tracheostomy at the front line, it was possible to compare results from two war fronts-one in the north with good front-to-base hospital communications and one in the south with very poor communications. No observable difference in the survival of patients with very severe facial injuries was apparent. It is probable that the attendant head injury common in the major civilian maxillofacial injuries which result from road traffic trauma constitutes the main indication for tracheostomy. In Vietnam, tracheostomy figures for facial injuries vary from 14.3 per centI to 17 per cent.lO The morbidity cannot be underestimated, and many of these patients would not have had tracheostomies in Nigeria (Figs. 6 and 9). Pennl’ reports that the Israeli Medical Corps’ policy is to replace emergency tracheostomy by intubation were possible, as casualties are then easier to transport and bleeding wounds of the throat and neck can be packed. McIndoe2 states that eyelet wiring fails as a method of fixation for severe injuries and that the use of cast-metal splints is the method of choice. In this
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war experience with wiring techniques has shown that adequate fixation is achieved. The difficulties of preoperative planning have been emphasized, and in this context preliminary impressions were found to be impractical and useless. The most important factor in attaining union of jaw fractures is elimination of infection by adequate debridement and drainage. It was not fonnd that drainage delays healing of even nonsuppurating fractures, a view stated by Clarkson and associates.5 In fact, even when patients with 3- or 4-week-old infected mandibular fractures arrived at the unit with no semblance of healing, the regimen of cleaning, debridement, fixation, and drainage produced the same rate of healing as in patients seen within a few days of injury. It is remarkable that prolonged exposure of bone bathed in saliva is compatible with survival of the fragment. No mandibular fracture without a bone gap failed to unite, and many with bone gaps at initial examination (12.5 per cent) proceeded to union in continuity. In the latter group, use of all available healthy bone fragments, as advocated by Kwapis,6 contributed to success. Metal implants were used in a few cases to maintain the anatomic relationship of fragments. It was found that these were of only temporary use because of mechanical failure or infection. Such implants must be fixed by bolts rather than screws (Fig. 8). The concept of late primary closure of infected soft-tissue wounds is important.3 Primary suturing of gunshot wounds at the front was usually followed by complete breakdown, and it is better to pack such wounds open until they can be cleaned. Where there was tissue loss, it was found that good functional results could be obtained in most casesby the use of local tissue flaps at an early stage, and much extensive late reconstruction was avoided. Bone loss at the symphysis of the mandible is a much bigger problem than lateral loss in the body or ramus. In the latter group, excellent function is often achieved without resorting to bone grafts. It is important to realize that the length of time required for a bone graft to succeed is proportional to the length of the graft.5 Fatalities at this maxillofacial unit were very low. The only death was caused by massive secondary hemorrhage related to an apparently trivial penetrating injury in which a small shell fragment in the neck eventually resulted in complete erosion of the common carotid and jugular vein. It should be noted that of thirty-three deaths recorded by Clarkson and colleagues,5most were secondary to associated brain or brain-stem injury. In this war such patients could not survive long enough to reach the base hospital. The fact that many patients with massive jaw injuries survived for so long is a tribute to the ability of the Nigerian surgeons at the war front in ensuring that blood transfusion, antibiotic therapy, and tetanus and gas gangrene prophylactic regimens were always instituted in the most difficult of circumstances. This maxillofacial unit was established in 1968 by the Federal Nigerian Armed Forces Medical Service, the Institute of Health of Ahmadu Bello University, and the British Ministry of Overseas Development, as the result of a survey and report by Mr. T. G. Ward. We would particularly like to acknowledge the help received in the treatment of patients from Lieutenant Colonel Sho Silva and his colleagues of the Federal Armed Forces Medical Service and from Dr. R. I. Shamia.
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REFERENCES 1. Gillies, H. D.: Discussion on Surgical and Dental Treatment of Severe Facial Injuries, Trans. Med. Sot. London 41: 165, 1918. 2. McIndoe, A. H.: Surgical and Dental Treatment of Fractures of the Upper and Lower Jaws in War Time, Proc. Roy. Sot. Med. 84: 267, 1941. 3. Kazanjian, V. H.: An Outline of the Treatment of Extensive Comminuted Fractures of the Mandible, Amer. J. Orthodont. & Oral Surg. 28: 265, 1942. 4. Kazanjian, V. H.: Early Treatment of Gunshot Wounds of the Face and Jaws, Surgery 15: 22, 1944. 5. Clarkson,.P., Wilson, T. H. H., and Lawrie, R. S.: Treatment of Jaw and Face Casualties in the British Army, Ann. Surg. 123: 190, 1946. 6. Kwapis, B. W.: Early Management of Maxillo-facial War Injuries, J. Oral Surg. 12: 293, 1954. 7. Ben-Hur, N., Neuman, Z., and Snyderman, R.: Plastic Surgery in the Six Day War in Jerusalem, Plast. Reconstr. Burg. 41: 333, 1968. 8. Andrew, J. L.: Maxillo-facial Trauma in Vietnam, J. Oral Surg. 26: 457, 1968. 9. Morgan, H. H., and Szmyd, L.: Maxillo-facial War Injuries, J. Oral Surg. 26: 727, 1968. 10. Terry, B. C.: Facial Injuries in Military Combat: Definitive Care, J. Oral Surg. 27: 551, 1969. 11. Tinder, L. E., Osbon, D. B., Lilly, G. E., Salem, J. E., and Cutcher, J. L.: Maxillo-facial Injuries Sustained in the Vietnam Conflict, Milit. Med. 134: 668, 1969. 12. Hovell, J.: Personal communication, 1970. 13. Watson, J.: Personal communication, 1970. 14. Osbon, D. B.: Early Treatment of Soft Tissue Injuries of the Face, J. Oral Surg. 27: 480, 1969. 15. Irby, W. B.: Facial Injuries in Military Combat-Intermediate Care, J. Oral Burg. 27: 548, 1969. 16. Penn, J.: The Third Israeli-Arab War: June, 1967, Mediese Bydraes. 13: 396, 1967. Reprint requests to : M. D. Awty, F.D.S., M.R.C.S., Queen Victoria Hospital East Grinstead Sussex, United Kingdom
L.R.C.P.