In China, there has been a noticeable and substantial increase in firearm injuries to the maxillofacial area in recent years. Most of the firearm injuries treated in our department during the past 4 years have involved oral and maxillofacial wounds with retention of irregular fragments from low or middle velocity projectiles. These include small round projectiles made of iron or steel, lead shotgun pellets, and even sand. Projectile retention often leads to severe complications, such as foreign body reaction, secondary infections, and acquired defects, and has an aesthetic, functional, and/or psychological impact on the patient’s life. Knowing when and how to remove the fragments is essential to a successful procedure in the treatment of oral and maxillofacial firearm wounds.

Computed tomography (CT) navigation-assisted surgical procedures have provided an alternative for the surgical removal of metal fragments in oral and maxillofacial shotgun wounds. In recent years, the number of patients seen in our hospital with injuries to the maxillofacial area caused by automatic firearms, involving projectiles such as steel balls and lead bullets, has increased steadily. As a result of the poor penetration of these bullets, they are often retained in the maxillofacial soft tissue and bone. The treatment of this type of firearm injury has often been difficult and complicated when the operation has been performed with the use of traditional imaging modalities, including X-ray, ultrasound, and bar magnets, etc.

In this study, 24 patients suffering from projectile retention in the maxillofacial area were treated surgically under CT navigation combined with endoscope guidance. CT navigation combined with an endoscope for the removal of projectiles in the maxillofacial area can be carried out safely and accurately.

Patients and methods

Only patients who fulfilled all of the following criteria were included in this study: (1) The patient had experienced a firearm injury from a gun or explosion, etc. (2) The patient required a surgical procedure to remove the retained projectiles. (3) The retained projectiles could be detected by X-ray. (4) The patient presented to the hospital between January 2009 and September 2013 (the CT navigation system was introduced in the hospital in 2007; this method replaced the previous use of two X-ray machines). (5) The patient provided written informed consent to be included in the study.

Patients with retained projectiles in the craniocerebral area and thoracic cavity were excluded.

Of the 24 patients, 22 (91.7%) were male and two (8.3%) were female; the male-to-female ratio was 11:1. The mean patient age was 25.8 years (±15.5; range 17–39 years). The types of projectile retained in the face and neck region included, among others, iron balls, steel balls, and lead bullets, as shown in Table 1 .

Table 1

Detailed information of the 24 patients with firearm injuries.

No.	Sex	Age, years	Intraoperative blood loss, ml	Position	Type	Duration of surgery, min	Results	Year
1	Male	28	200	Skull base	Five iron balls	197	Normal	2009
2	Male	20	150	Posterior wall of the maxillary sinus	Copper bullets	81	Infection	2010
3	Male	18	120	The mandibular ramus	Lead bullets	78	Normal	2012
4	Male	21	90	The anterior maxillary sinus	Steel ball	64	Normal	2012
5	Male	19	20	Parapharyngeal	Iron ball	23	Normal	2011
6	Male	25	30	Orbital wall	Copper bullets	31	Normal	2013
7	Male	27	40	Inferior orbital rim	Lead bullets	39	Normal	2009
8	Male	24	30	Inner maxilla	Iron ball	45	Normal	2011
9	Male	35	50	Buccal space	Steel ball	47	Normal	2013
10	Male	23	80	Skull base	Copper bullets	59	Normal	2012
11	Male	21	40	The maxillary sinus	Steel ball	51	Normal	2013
12	Male	30	30	Suborbital space	Lead bullets	35	Normal	2010
13	Female	38	80	The trailing edge of the mandibular ramus	Steel ball	69	Normal	2010
14	Male	26	60	Infratemporal fossa	Steel ball	52	Normal	2013
15	Male	28	20	Chin muscle	Sand	24	Normal	2013
16	Male	27	50	In front of the cervical vertebra	Lead bullets	54	Normal	2011
17	Male	19	70	Pterygomandibular gap	Steel ball	65	Normal	2013
18	Male	39	70	Nasal septum	Lead bullets	44	Normal	2012
19	Female	22	30	Ethmoid	Other	37	Normal	2013
20	Male	29	50	Posterior wall of the maxillary sinus	Steel ball	51	Normal	2013
21	Male	21	70	Skull base	Lead bullet	64	Normal	2013
22	Male	17	50	The surface of the mandible	Glass	45	Normal	2011
23	Male	33	40	Skull base	Steel ball	55	Normal	2013
24	Male	28	50	Anterior wall of the maxillary sinus	Iron ball	48	Normal	2013

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