Ballistic traumas vary according to the weapon used, the veloc-ity of the bullet, the direction of the energy transferred from the bullet,
density and size of the tissue, and form and hardness of the bullet.

On the basis of the initial velocity of the bullet, firearms
can be categorized into infrasonic and supersonic types. Infrasonic firearms
have a bullet velocity less than 660 meters per second (m/s), whereas that of
supersonic firearms is above 660 m/s.

The extent of the injury depends on the degree of absorption
of kinetic energy produced by the bullet on impact, as well as on the resistance
offered by the tissue/body. Once the bullet reaches the body, it causes
contusion, skin introflection, and simple or excori-ated ecchymosis before it
penetrates the tissues.

The skin wound is typically a hole with frayed margins, whose
diameter is smaller than that of the bullet, owing to elastic retraction of the
skin. The injury that results from contact with the fired bullet is a solution
of continuity, which can be a perforating or penetrating wound (e.g., if the
bullet is trapped in the tissues) or a grazing wound (when the bullet grazes the
skin surface).


We report the case of a 19-year-old man who came to our
atten-tion 2 h after a ballistic trauma. The investigation conducted by the
ballistic expert reported the dynamics of the shot, indicating that it was fired
at close range, probably from a distance of less than 1 m, with a trajectory
from above to below; the 45◦ angle of inclination suggested that the bullet hit
the patient while he was on his knees.

Investigations of the patient?s lesions suggested that the
bullet entered from the left mandibular parasymphysis, making a small hole;
subsequently, the left chin region immediately below the lower alveolar process
appeared to have been fractured by the bul-let.

The bullet finally stopped in the submandibular area in the
suprahyoid region of the neck. Extraoral examination did not reveal hematic
diathesis or edema, and typical signs of a firearm injury were absent.

The bullet entry hole was only identified as such at a later
stage; it was very small and without the typical bullet wipe and blackening,
suggest-ing that some object had been put between the weapon and the point of
impact (Fig. 1).

The hole measured 0.7 cm in diameter, with irregular circular
margins, an erythematous area burned into the centre, and surrounded by softer

The extraoral examination showed a coronal fracture of tooth
31 and increased mobility of the frontal dental group and the whole inferior
alveolar process, as observed by 2-handed palpation. Digital inspection also
revealed the presence of a bone fragment within the sublingual floor; this
fragment was probably displaced after the bullet impact.

The authors opted for emergency surgical treatment (1 h after
arrival at the hospital, 3 h after the shooting) under general anesthesia to
restore the anatomy of the comminuted fractured bone. Bullet removal and
structural repair were prioritized.

The neurovascular complexity of the area adjacent to the
bullet required the careful work of a full team of doctors, including a plastic
surgeon to control the aesthetic impact of the treatment. No relevant vascular
damage was observed.

The first phase of the operation involved removal of bone
fragments displaced into the sublingual floor. After making a submarginal
incision to create a flap on the lingual side, the flap was separated and the
displaced bone fragments removed using surgical forceps.

Thereafter, the incision was closed using a horizontal
mattress suture. In the second, delicate, phase of the operation, the structure
of the shattered bone was restored by applying titanium osteosynthesis plates,
which were fixed with intraosseous screws in the chin region. To ensure greater
stability in the traumatized area, a ferula ligature of the lower frontal group
was also performed at the same time.

The third phase of the operation, involving removal of the
bullet, was the most critical because of the extreme mobility of the foreign
body within the soft tissues. This required the use of a dynamic luminance
intensifier to guide the surgeon?s hand towards the bullet. The region in which
the bullet had lodged was identified by skull radiographs, obtained in several
projections, along with ultrasound investigations before and after surgery.
After extraoral incision of the submandibular area, diastasis of the
subcutaneous areas, and separation of the muscular-fascial planes, the bullet (diameter,
approximately 9 mm) was removed (Fig. 2).

Thereafter, hemostasis of the involved tissues was achieved,
and intradermic sutures (using reabsorbable material) and cutaneous sutures (using
non-reabsorbable material) were inserted. The course of the bullet did not
affect either the major vessels or the major nerve trunks; therefore, the
postoperative course was shorter than expected, in view of the type of injury
and the area of the body involved.

As a consequence of the combined orthopedic?orthodontic
rehabilitation, the patient was able to regain full functionality in mastication,
phonation, and deglutition.


In this case report, we describe a very unusual gunshot wound,
compared to typical ballistic trauma, which initially misled the doctors at the
Emergency Ward about the actual traumatic noxa.2 Bullet entry holes are
typically characterized by a stellate entrance wound caused by gas expansion (for
a shot fired at close range) or by an entrance wound with bullet wipe and an
abrasion ring (for a shot fired from >50 cm).1,2 In the present case, the
distinctive features of a firearm injury were absent, and the lack of bleeding
and edema made the case difficult to interpret without additional diagnostic
investigations. Although the area pierced by the bullet was rich in
neurovascular structures, many of which are extremely important, the patient did
not suffer any severe injury of the neurovascular structures. Instead, he
presented only with the fracture of the chin region, along with compromised
stability of the lower alveolar process.

Our case report shows that ballistic trauma can occur with
extremely variable characteristics, making diagnosis difficult. Experience and
an open-minded approach when assessing trauma patients may facilitate diagnosis
without the requirement of further investigation. However, if there are no
injuries to internal organs or neurovascular structures and if surgeons and
dentists work together to plan treatment, complete aesthetic and functional
rehabilitation can be rapidly achieved.

Conflict of interest
The authors declare that they have no competing interests.

No external funding was used for this study.

Ethical approval
Written informed consent was obtained from the patient for publication of this
case report and the accompanying images. A copy of the written consent is
available for review by the Editor-in- Chief of this journal on request.

Authors? contributions
Francesco Inchingoloa,Marco Tatullo, Massimo Marrelli, Alessio D. Inchingolo, Giorgia Pinto, Angelo M. Inchingolo, Gianna Dipalma

FI and GD participated in the surgical treatment and in the follow-up examinations. MT drafted the manuscript and revised the literature sources. MM and GP participated in the follow-up examinations.
ADI and AMI revised the literature sources. All authors read and approved the final manuscript.

1. Shelton DW, Albright CR. Study in wound ballistics. J Oral Surg 1967;25: 341.
2. Dojcinovic I, Broome M, Hugentobler M, Richter M. Unusual ballistic trauma of the face with a less-lethal launcher. J Oral Maxillofac Surg 2007;65: 2105?7.