Battlefield Jaw Injuries to US Soldiers Increasing

Laird Harrison

February 22, 2013

Americans fighting in Iraq and Afghanistan are more likely to have injuries to their jaws than Americans did in previous wars, according to results from a new study by Michael R. Zachar, DDS, from the San Antonio Military Medical Center, Fort Sam Houston, Texas, and colleagues.

The severity of these injuries poses challenges to physicians whose experience is primarily in civilian life, said corresponding author Rodney Chan, MD, chief of plastic and reconstructive surgery at the US Army Institute of Surgical Research, Fort Sam Houston.

Dr. Zachar and 5 colleagues at Fort Sam Houston published a survey of mandibular injuries online January 25 in the Journal of Oral and Maxillofacial Surgery.

"When we got out there, we found that the type of injuries were not the same as the ones we see here, which are mostly from motor vehicle accidents and bar fights," Dr. Chan told Medscape Medical News.

Body armor protects the torsos of American soldiers, but many still suffer severe injuries from explosives. "Because of the body armor, the most common areas of injury are the head, neck, and extremities," said Dr. Chan.

For the study, Dr. Zachar and colleagues reviewed the Joint Theater Trauma Registry, a database of all US service members treated by military physicians from October 2001 to April 2011, and identified 391 patients who had suffered mandibular fractures.

They found that 61.3% of the patients in the registry were injured with explosives and 12.5% with ballistics. The patients averaged 1.5 mandibular fractures each. Of these injuries, 33.4% were angle, 19.6% were body, 21.2% were condyle, 6.9% were coronoid, 5.7% were dentoalveolar, and 13.2% were symphyseal/parasymphyseal.

Patients were excluded if they died or had nonbattle injuries.

The researchers identified a subgroup of 45 patients treated at the San Antonio Military Medical Center (formerly known as the Brooke Army Medical Center) and used statistical calculations to ensure that the subgroup was representative of the whole, taking into account age, gender, mortality rate, theater of operation, or branch of service.

The distribution of fractures was similar in the subgroup. With the more detailed data that were available on these patients, the researchers found that 84% of them had comminuted fractures, 31% had segmental losses as the result of their fracture, and 73% had panfacial fractures.

In contrast to civilian mandibular injuries, most of which are closed, the patients were more likely to have open, comminuted, and segmental injuries.

The severity of these injuries led to 81% of the patients being evacuated to level 5 military medical centers in the United States. In comparison, only 57% of facial injuries require evacuation to higher levels of care, the researchers report.

Dr. Chan said the data led him to several recommendations for oral surgeons serving in theaters of war. First, he said, "don't burn any bridges." Physicians should be aware of the need for later reconstructive surgery and preserve body parts.

For example, surgeons sometimes use the fibula osteocutaneous free flap in reconstructing the mandible. "I would think a lot before amputating the leg," said Dr. Chan. "If you take the leg away, you're taking away an option."

He also recommended thorough debridement . "A lot of the injuries are out in the field with a lot of soil and feces, so sometimes infection can take place," he said.

He also urged reestablishing good oral alignment. "Early tracheatic and airway control is important," he said.

Dr. Chan also emphasized that physicians dealing with battlefield wounds to the mandible will need to do soft-tissue as well as hard-tissue reconstruction. "Otolaryngologists and oral surgeons are mostly experienced with hard tissue," he said.

Asked to comment on the study, Barry Steinberg, MD, DDS, PhD, told Medscape Medical News that the kinds of injuries documented corresponded with the ones he saw in his own experiences as an oral surgeon in Iraq in 2008 and Afghanistan in 2010.

Dr. Steinberg, an associate professor of oral and maxillofacial surgery at the University of Florida in Jacksonville, said he did not have all the equipment he needed to do such procedures as bone plating in the theaters of battle.

That was a mainly a problem when he was treating citizens of Iraq and Afghanistan, because these patients were not evacuated to higher level medical centers, he said.

However, he also said that he did not feel he was lacking the expertise to work with the soft-tissue injuries he encountered. "It depends on the training of the people over there," he said.

Dr. Chan and Dr. Steinberg have disclosed no relevant financial relationships.

J Oral Maxillofac Surg. Published online January 25, 2013. Abstract