Maxillofacial Trauma Team

01 / THE PATIENT ARRIVES

Airway secured, bilateral mandibular destruction still to solve.

The patient presented after a facial gunshot wound. Emergency tracheostomy had already secured the airway. Examination documented lacerated and contused facial wounds, a projectile entry wound and communication with the oral cavity.

The skeletal injuries included multiple bilateral mandibular fractures with simple, compound and comminuted components, a mandibular alveolar fracture, dental avulsion and loss of bone on the left side.

De-identified three-dimensional CT reconstruction showing extensive bilateral mandibular fragmentation — Three-dimensional CT reconstruction. All patient and institutional identifiers were removed from the public image.

02 / THE WORKING DIAGNOSIS

One mandible, two different mechanical and biological environments.

The right side required dependable stabilization to re-establish mandibular continuity. The left side combined comminution, bone loss and direct oral exposure, creating a substantially greater contamination risk and a poor environment for extensive hardware placement.

The remaining teeth and occlusal relationship were limited but clinically valuable. They offered a reference for restoring mandibular position and supporting a less invasive strategy on the left.

Archive chronology

The case was treated in June 2006. The surviving image series contains assessment, operative and postoperative records from different dates within that month.

03 / POSSIBILITIES AND DECISION

Treat each side according to what it could safely support.

The team considered rigid internal fixation for the right-sided fractures and a more conservative, semi-rigid strategy on the left, using the occlusion and remaining teeth as positional references. The existing tracheostomy facilitated maxillomandibular fixation without competing with the immediate airway plan.

Extensive exposure and rigid hardware placement across the contaminated left defect could have increased infection risk and further disrupted the tissues surrounding the area of bone loss. The chosen plan therefore combined surgical stability on the right with protection of the biologic and muscular envelope on the left.

01Secure the airwayEmergency tracheostomy was already present.

02Recover occlusionRemaining teeth provided a positional reference.

03Stabilize the rightOpen reduction and rigid internal fixation restored continuity.

04Protect the leftConservative management limited additional disruption in the contaminated defect.

04 / OPERATIVE RECORD

Occlusion-guided fixation plus selective open reduction.

Maxillomandibular fixation used the remaining dentition to guide the occlusion despite the limited number of mandibular teeth. On the right, an extraoral approach exposed the fractured mandibular body and angle. The fragments were reduced and stabilized with rigid plate fixation.

The left side was maintained through the occlusion-guided, less invasive strategy described by the curator. The objective was to preserve the early hematoma, inflammatory response and soft-tissue envelope while avoiding additional contamination and devascularization at the site of bone loss.

Intraoperative maxillomandibular fixation using the remaining teeth as an occlusal guide — Maxillomandibular fixation used a limited residual dentition to recover and maintain the occlusal relationship.

Open reduction of the right mandibular fracture — Reduction of the right mandibular fracture through an extraoral approach.

Completed rigid internal fixation of the right mandible — Rigid internal fixation restored stability on the right side.

05 / RECOVERY AND LONG-TERM OUTCOME

No additional operation and no recorded complication.

The postoperative course required no additional surgery, and no complication was recorded in the submitted history. Early follow-up documented a functional and esthetic occlusion.

Focused early postoperative clinical image showing the recovered occlusal relationship — Early postoperative occlusal relationship. The image was cropped to reduce identification.

The curator reports that bone formation and remodeling were complete after one year. At 15 years, the patient remained functionally and esthetically rehabilitated and had subsequently received implant and prosthetic rehabilitation.

Patient smiling at the 15-year follow-up — Fifteen-year follow-up. The image is cropped from an authorized personal record and documents the long-term esthetic result.

06 / WHAT THE TEAM LEARNED

Conservative and invasive treatment were complementary, not contradictory.

In the team's interpretation, the early clot and inflammatory response helped maintain the relationship between the injured bone and surrounding musculature on the left. Preserving that environment may also have reduced cicatricial muscle retraction associated with the osseous defect.

The case supports a broader principle from Professor Lasco's school: the most aggressive reconstruction is not automatically the most appropriate treatment for every region of the same injury. Stability, contamination, remaining anatomy, occlusion and biological preservation must be balanced separately.