Patterns of maxillofacial injuries caused by terrorist attacks in Iraq: retrospective study


Over the past 5 years, Iraq has witnessed daily terrorist attacks mainly using improvised explosive devices. The aim of this study was to analyze the patterns of maxillofacial injuries caused by terrorist attacks in a sample of Iraqi casualties. Records from two hospitals, including 551 patients who sustained maxillofacial injuries due to terrorists attacks, were analyzed according to the patients’ age, sex, site of injury, type of injury and cause of injury. Concomitant injuries and mortality were also considered. The most common age group affected was those aged 15–29 years. Most of these injuries were caused by improvised explosive devices (71%). More than one facial zone was injured in 212 patients (38%). Isolated soft tissues injuries were detected in (54%) of victims. Pure maxillofacial injuries comprised 33%. The most common injuries associated with this type of trauma were eye injuries (29%). The mortality rate was 2% from pure maxillofacial injuries. Terrorist attacks cause unique maxillofacial injuries, which should be considered a new entity in the trauma field.

During the past 5 years, Iraq has witnessed daily terrorist attacks, mainly caused by roadside bombs, explosive vehicles and suicide bombers. These events became worse in 2005–2006, when insurgent groups began targeting the Iraqi population. Terrorism in Iraq is part of a global phenomenon. Most attacks were against civilians with the aim of destroying property to achieve political goals, create terror, chaos and social destruction . This terrorism is highly organized and committed by a group of terrorists with the capacity to inflict disaster on a large scale . Improvements in the explosive devices made by the terrorists means they are capable of producing mass casualties because their activities are directed towards crowded places. Their bomb blasts produce multidimensional injuries, modified by the amount and type of explosive, the nature of the environment and the people involved . In addition to conventional war, the rise of terrorism has added another dimension to the potential for war-like injuries . Other researchers have discussed the injuries caused by terrorism as a separate type of intentional injury . The incidence of maxillofacial terror-related casualties is high , but there are few studies about this type of injury. The complex anatomy of the maxillofacial region means that severe trauma to the area has the potential to cause significant esthetic and functional disturbances. The incidence of maxillofacial injuries in wounded soldiers during conflicts from 1914 to 1986 was 16% . This ratio is higher than expected considering that the head and neck form about 12% of the body surface area. The involvement of the face and neck in terror attacks will be the same as war injuries or even higher. Terrorists usually direct their actions against large civilian gatherings, where people do not have the protective gear worn in a war setting, which could result in more severe injuries. The aim of the present study was to analyze the patterns of facial injuries caused by terrorist attacks in a sample of Iraqi victims.

Patients and methods

This retrospective study was carried out using records from two hospitals from June 2005 to June 2006. 215 patients were included in the study. They were victims of terrorism who had been evacuated from the regions north of Baghdad, mainly from Dayala and Kirkuk governorates. The records of another 336 victims admitted to a hospital 100 km south of Baghdad were also used. All the victims had sustained maxillofacial injuries, alone or associated with other injuries, caused by terror attacks. 551 patient records met the inclusion criteria. Burn injuries were excluded from the analysis because these patients are managed in specialized centers. The study received ethical approval.

The data were analyzed to determine the age, sex and cause of the trauma according to the weapon used. The facial trauma was categorized according to the facial thirds involved, the type of soft tissue injuries and facial bone fractures. The associated injuries and mortality were also considered.

Descriptive statistic analysis was used in this study. The data was tabulated and processed using statistical package SPSS (Version 16; SPSS Inc., Chicago, IL, USA).


Males accounted for 63% (349) of patients; females accounted for 37% (202). In all age groups, males were affected more than females. The age of the treated patients ranged from 3 to 68 years, but the most common age group affected by terrorist’s attacks was those aged 15–29 years ( Table 1 ). 212 patients (38%) were injured in more than one area of the facial thirds ( Fig. 1 ), followed by the lower facial third ( Table 2 ). Most of these injuries were caused by improvised explosive devices (389 victims; 71%), including suicide bombers, roadside bombs and explosive vehicles ( Fig. 2 ) ( Table 3 ). Isolated soft tissues injuries were detected in 297 patients (54%) mainly in the form of multiple soft injuries, including penetrating, lacerated and avulsed injuries ( Table 4 ). 94 patients (17%) had multiple fractures of the facial skeleton ( Table 5 ). 182 (33%) traumatized patients had pure maxillofacial injuries ( Figs. 3 and 4 ). Eye injuries were the most common injuries associated with this type of trauma (29%) ( Fig. 5 ), followed by head injuries (22%) ( Table 6 ). 4 patients (2%) died from pure maxillofacial injuries; three of them complaining of severe trauma in the mid face region.

Table 1
Sex and age groups of the injured patients.
Age group (years) Male (no.) % Female (no.) % Total (no.) %
<15 73 13.24 39 7.07 112 20.3
15–29 119 21.59 52 9.43 171 31.03
30–44 87 15.78 55 9.98 142 25.77
45–60 59 10.7 51 9.25 110 19.96
>60 11 1.99 5 0.9 16 2.9
Total 349 63.3 202 36.6 551 100

Fig. 1
Terrorist attacks affect a wide range of victims of both sexes and all ages. (A–C) The exposed parts of the body, including the face, are affected more than other areas by this type of trauma.

Table 2
Distribution of injuries according to facial zone.
Facial zone Upper Middle Lower More than one
No. 100 117 122 212
% 18.1 21.4 22.1 38.4

Fig. 2
(A–C) Fragments of the explosive device penetrate the maxillofacial region.

Table 3
Types of facial trauma produced by different weapons.
Type of weapon Soft tissue Hard tissues Hard and soft tissues Total no. %
Improvised explosive device 199 71 119 389 70.59
Gunshot 67 35 102 18.51
Mortars and rockets 31 13 16 60 10.88
Total no. (%) 297 (53.9) 84 (15.2) 170 (30.8) 551 100

Table 4
Soft tissue injuries (no. 416).
Type Single no. Multiple no. Avulsion no. Total no. %
+Soft tissues 40 201 56 297 53.9
++Soft tissues 24 66 29 119 21.5
+Isolated soft tissues injuries. ++Soft tissues injuries associated with facial bone injury.

Table 5
Distribution of facial skeleton trauma.
Site No. %
Upper third 12 2.17
Zygoma and orbit 27 4.9
Nasoethmoid 12 2.17
Le Fort (I, II, III) 25 4.53
Mandible 32 5.8
Dentoalveolar 52 9.43
Multiple fractures 94 17.05
Total 254 46

Fig. 3
Terrorists attacks can produce different types of facial trauma according to the weapon used and the effects of the blast mechanism. (A) and (B) Two male victims who sustained facial trauma as a result of secondary blast injury. (C) A young female patient with severe mid face trauma caused by the collapse of a building. (D) and (E) A 19-year-old male victim of assassination; a high velocity weapon caused comminuted fracture of the mandible.
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Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Patterns of maxillofacial injuries caused by terrorist attacks in Iraq: retrospective study

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