Trauma in Iraq's Wars: Assessment and Management of Craniofacial Injury.

As the most prominent portion of the human body, the face embraces a multifaceted responsibility for functionality and survival while contributing to identity and self-image. Inopportunely, due to its distinctive anatomical location, the face as a unit is highly suspectable to trauma, particularly in warfare. As a result, facial injury creates a physical and psychological trauma that needs to be addressed immediately. In the following article, a detailed literature review was conducted to examine the interplay between facial injuries throughout multiple wars in Iraq and their management. The authors found a significant increase in facial injuries due to shell fragments corresponding with modern advances in warfare targeting mass casualties. The capacity to manage the magnitude and level of trauma observed in Iraq requires a substantial amount of resources and a systematic approach that unfortunately is unattainable in a country that is still struggling to rebuild after decades of oppression and war. Due to the circumstances, surgeons have to rely on training and experience to provide the best care for their patients and it is imperative that we continue to train our surgeons to rely on their skills and experience to ensure a high level of care with limited resources and lack of technology.

Missile War Injuries of the Craniofacial Region.

Many factors govern the nature, severity, and outcome of missile war injuries and associated soft tissue damages. Managements of primary phase and trauma care have improved significantly. Many of these injured victims survived and require immediate care for primary phase management. Secondary phase was achieved by reconstruction of soft tissue by local, regional flaps, and bony defect by bone grafting.There is no consensus on timing of treatment of bone and soft tissue of missile war injuries.Currently, in Iraq, anti-government's protestors' movement for the last 3 months mainly unemployed young people demanding for human rights has resettled in 22,000 people being injured. This includes more than 600 young men who were assassinated by unknown killers through confrontation with security and police men using tear gas canisters and sound bombs. The demonstrators used mini cars (Tuck Tuck) for attacking policemen and security people and used them for transferring injured demonstrators as ambulance to a special tent in the Tahrir Square for receiving first aid.

The use of sodium tetradecyl sulphate for the treatment of venous malformations of the head and neck.

INTRODUCTION: Vascular malformations have devastating cosmetic effects in addition to being associated with pain and bleeding. Sclerotherapy has been used as an effective therapeutic modality for the management of vascular malformations. The purpose of this case series is to describe our clinical experience of using sodium tetradecyl sulphate (STS) 3 % in the treatment of venous malformation lesions of head and neck. MATERIALS AND METHODS: Thirteen patients were included in this study (three male and ten female; age range between 8 months and 54 years; mean age 18.2 years, ±SD 15.71). The patients were treated by 3 % STS intralesional injections. Of the thirteen patients treated, complete resolution occurred in four patients (28.57 %), a good response occurred in five patients (35.7 %), a moderate response in two patients (14.28 %), a mild response in two patients (14.28 %) and no response in one patient (7.14 %). The side effects encountered in all patients were pain and edema after injection which was controlled by oral analgesics and an intramuscular injection of dexamethasone. In addition, two patients developed a superficial ulceration (11.76 %) which healed uneventfully, and one patient developed ecchymosis after injection (5.88 %). CONCLUSION: Sclerotherapy with 3 % STS is a simple, safe, and effective modality for the treatment of venous malformations.

Biological reconstruction of the temporomandibular joint by chondro-osseous graft: clinical and experimental study.

This study includes 35 children treated by reconstruction of the temporomandibular joint (TMJ) by chondro-osseous graft harvested from iliac crest for management of 2 diseases; the first one was ankylosis of the TMJ. There were 25 cases of 9 girls and 16 boys, and there were 10 cases of hypoplasia of the TMJ of first-arch dysplasia syndrome or hemifacial microsomia, of which 4 were females and 6 were males. Their ages ranged between 4 and 13 years (mean, 8.5 years); follow-up of the patients ranged from 3 to 5 years. All patients showed good result and without recurrence of ankylosis or restriction of mouth opening, and growth of the face was acceptable and without using osteotomies for correction of jaw relationship or distraction techniques.Experimental studies on rabbits were performed to prove the condyle as growth center and after excision of the head of condyle and disk in newly growing rabbits of 3 months of age; after 3 months of follow-up, we observed severe deformity of the rabbits' mandible, and the mandible deviated to the affected side on the first experiment. In the second experiment, reconstruction of the TMJ and condyle of the rabbits by chondro-osseous graft harvested from iliac crest of the same rabbit was carried out in 8 animals to assess the viability and value of chondro-osseous graft to replace the TMJ. After 3 months, all animals were killed. Postmortem studies were done to assess the healing process of the graft or any resorption of the graft. Histological studies of the graft showed 4 layers: the first articular layer was thick because of functional demand of masticatory process for hard food of rabbits; the second layer was the granular mesenchymal stem cells layer, very active and multiple layers that represent the proliferative layer; the third layer showed conversion of cartilage cells to osteoid cells, and the fourth layer was the osteoid layer. On follow-up of clinical cases, the graft was continued for functional demand of growth, repair, and remodeling of the condyle.

Missile war injuries of the face.

In a society struggling to rebuild its country after 3 decades of years of dictatorships and wars, Iraqi maxillofacial and craniofacial surgeons play a critical role in treatment of many most serious terrorist missile injuries of the face by ongoing conflict in Iraq. This study reflects our surgical techniques of treating explosive missile injuries and other combat- and terrorism-related injuries and also evaluates the immediate and secondary phase managements of patients with missile injuries. This study includes 235 patients with missile war injuries of the face during a period of 4 years; all injured patients were treated in the Maxillofacial Unit of Surgical Specialties Hospital, Medical City, Baghdad. There were 195 men and 40 women; their ages ranged from 1 to 70 years (mean, 39.5 years). Posttraumatic missile facial deformities were classified as follows: 95 patients (40.43%) had bone loss; 72 patients (30.64%) had soft tissue loss; 33 patients (14.05%) had orbital injuries; and 35 patients (14.90%) had other deformities of scar contracture, fistula, and sinus formation. Two techniques were used for reconstruction of the bony defect, either by bone chips carried by osteomesh tray harvested from the iliac crest or by free block of corticocancellous bone graft from the iliac crest. Soft tissue reconstruction was done by local flaps and regional flaps such as lateral cervical and cervicofacial flaps, and the orbit was reconstructed by bone graft, lyophilized dura, and sialastic implant. Scar contracture was treated by scar revision and sinus tract excised at the same time of scar revision. In conclusion, the primary phase required an urgent airway management, controlling an active bleeding by surgical intervention; most entrance and exit wounds as well as retained missiles were located in the cheek, chin, and mandibular body, with few cases of mortality due to complications related to head injuries. The secondary phase management of deformities of the face as a complication of missile injuries was classified as bone loss, soft tissue loss, combined bone and soft tissue loss, and others (sinus tracts and poor scars).

Management of maxillofacial injuries in Iraq.

These clinical studies reflect the experience of the author in managing 673 patients treated during the last 8 years. All patients were treated in the Maxillofacial Unit, Surgical Specialties Hospital, Medical City, Baghdad, and in the author's private clinic. Included patients were 530 males and 143 females; patients' age ranged between 1 year and 75 years (mean, 38 y). Distribution of injuries was as follows: fracture of the mandible, 287 (42.64%); middle third injuries, 39 (5.79%); orbital injuries, 236 (35.07%; including 12 cases with cranioorbital injuries); injuries in children, 27 (4.0%); fracture of the zygoma, 52 (7.73%); and fracture of the nose, 40 (5.94%).Maxillofacial injuries in this study were classified as follows: (1) craniomaxillofacial with head injuries and cerebrospinal fluid leak; (2) fracture of the middle third including Le Fort I, II, and III and midline split in the face; (3) fracture of the mandible as an isolated injury or as part of a facial skeleton injury; and (4) isolated complex injuries of the zygoma, the orbital skeleton, and the nasoethmoidal region.The technique used for treating middle third injuries was external fixation either by halo frame (with vertical rods and cheek wires) or by box frame (using 4 external pins connected by rods) or internal fixation by suspending the middle third with internal wires (0.5 mm stainless steel) from the zygomatic process of the frontal bone beneath the zygomatic arch down the lower arch bar. Fractures of the mandible were treated by gunning splint with intermaxillary fixation (IMF) or with open reduction and fixation by stainless steel wire with IMF or by IMF screw or by an arch bar and IMF. Other fractures such as fracture of the orbit were treated by bone graft, sialastic, or lyophilized dura with open reduction. Fractures of the zygoma were treated by open reduction and fixation with stainless steel wire and bone graft or by reduction without fixation. Fractures of the nose were treated by reduction with straightening of the septum with a splint (lead splint or polythene) or by external splint with plaster of Paris. With the techniques used, results from managing these cases were satisfactory.

Surgical managements of subluxation and dislocation of the temporomandibular joint: clinical and experimental studies.

Subluxation and dislocation of the temporomandibular joint (TMJ) are very unpleasant and distressing conditions to patients; they are not common diseases, but large groups of people in countries such as Yemen and Somalia are affected owing to daily chewing of Qat for several hours every day, but in Iraq, the conditions are not common. These clinical studies were conducted on 133 patients: 87 men and 36 women; their age ranged between 18 and 72 years (mean, 45 y), and their complains were difficulties of chewing food, speech, laughing, or yawning. Patients were divided into 3 groups: the first group included 65 patients (45.53%) who were treated by surgical reconstruction of the TMJ by using a fingerlike fascial flap from the temporal fascia for reconstruction of a lax capsule and reenforcement and a block of corticocancellous bone graft from the iliac crest squeezed and impacted in a gap in front of the eminence of TMJ; the second group included 15 patients with delayed dislocation of TMJ (12.20%) who were treated by surgical release fusion of the capsule and condyle from the infratemporal fascia with reenforcement of the capsule by reverse L-shaped plication technique and eminectomy; and the last group included 45 patients with acute dislocation of the TMJ (34.96%) who were treated by modified manual reduction, and follow-up of the patients was between 1 and 20 years. An experimental study was done on rabbits to support our clinical study by using a temporal fascial flap for the reconstruction of a rabbit TMJ capsule, and the aim was to show that any pathologic changes might occur in the capsule or the condyle. The result was very optimistic, and there were no cellular changes observed in the condyle or surrounding structures.

Management of missiles injuries of the facial skeleton: primary, intermediate, and secondary phases.

This study included 235 patients with missile injuries of the facial skeleton, who were treated in the Maxillofacial Unit of the Hospital of Specialized Surgery in Medical City, Baghdad, Iraq, during a period of 4 years of war, since Iraq became the international battlefield for terrorism. There were 195 men and 40 women, with ages ranging from 1 to 70 years (mean, 39.5 years); all patients had severe facial injuries and posttraumatic missile deformities, including 27 patients with orbital injuries. This study also evaluates the management of the immediate, intermediate, and secondary phases.Deformities of the facial skeleton as a complication of missile injuries were classified into the following cases: 95 patients (40.43%) had bone loss, 72 patients (30.64%) had soft-tissue loss, 33 patients (14.05%) had orbital injuries, and 35 patients (14.90%) had other deformities of scar contracture, fistula, and sinus formation.The bony defects of the mandible were reconstructed by both bone chips carried by osteomesh tray harvested from the iliac crest in 24 patients and by block of corticocancellous bone graft from the iliac crest in 38 patients for reconstruction of the mandible, 4 cases for maxillary reconstruction, and 4 cases of orbital floor defect. K-wire was used in 23 cases for holding missing segments of the mandible. Soft-tissue reconstruction of the face was done in 72 cases, local flaps were used in 30 cases, regional flaps including lateral cervical flap in 10 cases, and cervicofacial flaps in 11 cases. The orbit was reconstructed by bone graft, lyophilized dura, and silastic implant. Low-velocity bullet injury to the frontal part of the head was treated by coronal flap, as an access in 6 cases required craniotomy and dura was reconstructed by galea or temporalis muscle. Scar contracture was treated by scar revision, and sinus tract was excised at the same time of scar revision. Primary phase required an urgent airway management, controlling an active bleeding by surgical intervention; most entrance and exit wounds as well as retained missile were located in the cheek, chin, and mandibular body. Few cases were reported of mortality due to complication related to head injuries.

Reconstruction by lateral cervical flap of perioral and oral cavity: clinical and experimental studies.

These clinical studies include 75 patients, followed up for 2 to 5 years: 37 females and 38 males. Age ranged between 5 and 81 years (median, 46 years). These cases were seen during a period of 6 years. There were 61 cases of oral squamous cell carcinoma; these cases include 25 cases of well-differentiated squamous cell carcinoma, 24 cases of moderately differentiated squamous cell carcinoma, and 12 cases of poorly differentiated squamous cell carcinoma. These cases were treated by adjuvant chemotherapy with radical surgery and deep x-ray therapy. In 23 cases, the lateral cervical flap (LCF) was used as an excess for radical resection of supraomohyoid neck dissection; in 10 cases, the LCF was used for reconstruction of cases with posttraumatic missile injuries, and in 4 cases, platysma muscle flap was used for reconstruction of underdeveloped masseter muscle in cases with mild hemifacial microsomia. Experimental studies were performed on rabbits for reconstruction of the lateral side of the tongue and submental region to assess the viability of LCF. In conclusion, the flap proved to be an ideal and most reliable flap for reconstruction of both perioral and oral defects after radical cancer surgery and posttraumatic missile injury deformities.

Temporomandibular joint reconstruction with a 2-part chrome-cobalt prosthesis, chondro-osseous graft, and silastic: clinical and experimental studies.

Seventy-six patients including 27 females and 49 males, with ages ranging between 4 and 35 years (mean, 19.5 y), all experienced loss of weight, stiff temporomandibular joints and inability to chew food, and facial deformities. These patients were treated in the Maxillofacial Unit, Surgical Specialties Hospital, Medical City, Baghdad, Iraq, using 4 different techniques according to the requirement of each case and the facilities available. These patients were divided into 4 groups: the first group consists of 16 children (21.06%) treated with a chondro-osseous graft; the second group, 10 children (13.16%) treated with a 2-part chrome-cobalt prosthesis; the third group, 32 children (42.11%) treated with a Sialastic rubber silicone implant (Koken Co, Tokyo, Japan); and the fourth group, 18 children (23.69%) treated with interposition arthroplasty with a temporalis muscle flap. The follow-up period of the cases ranged between 3 and 15 years. Experimental studies were done on using rabbits to assess the viability of the chondro-osseous graft and on monkeys to demonstrate the biological acceptability of the 2-part chrome-cobalt prosthesis. The aim of this clinical and experimental study was to show our experience in managing difficult tasks that craniofacial or maxillofacial surgeons may face and to share these experiences with other colleagues all over the world.

Reconstruction of the mandible by bone graft and metal prosthesis.

This clinical research was carried out in the Maxillofacial Unit, Surgical Specialties Hospital, Medical City, Baghdad, and included 188 patients with mandibular defects. The patients' ages ranged from 4 to 70 years (mean, 37 years); 60 of them were female, and 128 were male. One hundred twenty-six patients represent 67.03% of total cases with benign and locally aggressive tumors and malignant tumors of the mandible and oral cavity. Eighty-four cases (44.68%) of these were benign, 42 cases (22.34%) were malignant tumors, and 62 patients constitute about 32.98% with mandibular defect of posttraumatic missile injuries. Reconstruction of the mandible were done by a variety of techniques ranging from immediate reconstruction of the mandible by chrome-cobalt prosthesis, Kirschner wire, rib graft and bone graft from the iliac crest, and other additional technique of reimplanted condyle, secured with bone graft, and Dacron osteomesh tray carrying cancellous bone harvested from iliac crest. Long-term follow-up ranged between 5 and 10 years.The aim of these study was to share experience and to present an interesting pathology and methods of reconstruction of the mandible by metal prosthesis and bone graft; the management of these cases was a difficult task to be approached in some cases and was a surgical challenge to us.

Management of injuries of the orbital skeleton.

These clinical studies were carried out in maxillofacial unite, 10th floor, Surgical Specialties Hospital, Medical City, Baghdad. These orbital injuries included 236 patients during 15 years of experience. Their ages ranged from 2 to 72 years (mean, 37 years); 172 were male, and 64 were female. Orbital injuries are classified into isolated orbital walls, roof, floor, lateral wall, and zygoma and medial wall and complex wall injuries, as orbital skeleton injuries, or as part of cranio-orbito-facial injuries. There were 110 cases (46.6%) with orbital floor, and 85 cases (36%) with lateral wall and zygomatic complex injuries; 6 cases (3.6%) had isolated roof injuries; there were 15 cases (6.3%) with medial wall fractures and dislocation of medial canthal ligaments; 8 cases (3.3%) were orbital skeleton injuries with superior orbital fissure syndrome in 2 cases and eyeball laceration in 1 case, and 12 cases (5.08%) were cranio-orbito-facial injuries. These cases were treated and reconstructed by chrome-cobalt mesh for orbital floor, and also, Silastic rubber silicone was used in the floor and roof. Bone graft was used for reconstruction of large defect of the floor and medial wall, and Silastic was used for secondary operation for reconstruction of the floor as additional layer in cases with slight resorption of bone graft to correct residual enophthalmos, and lyophilized dura was used for reconstruction of the roof. Follow-up of the cases was extended for 15 years. The aim of these studies was to show some interesting clinical cases and surgical challenges for the management of these cases.

The managements of orofacial tumors of children in Iraq.

These studies were carried out in the maxillofacial unit, surgical specialties hospital, medical city, Baghdad, included 55 patients with orofacial tumors; their ages ranged from 2 days to 14 years (mean, 7 years). Twenty-eight of them were girls, and 27 were boys. Tumors included 20 cases of benign tumors and 35 cases malignant. Treatment modalities ranged from complete surgical excision, surgical shaving operations, and deep x-ray therapy (DXT; radiotherapy) for some benign tumors. The management of malignant tumors was carried out by the use of chemotherapy, chemotherapy and DXT to radical surgery, or radical surgery with DXT. Reconstruction of the mandible was carried out using a rib graft or a block of a corticocancellous bone graft from the iliac crest with reimplantation of the condyle after resection from the tumor and fixed by rigid fixation to the bone graft. Temporary reconstruction of the mandible done by Kirschner wire for malignant tumors required a postsurgical DXT. A temporalis muscle flap was used for the augmentation of the orbit with a frontoorbital flap after radical excision of a malignant tumor of the orbit, and a silastic implant (silicon rubber) was used for reconstruction of the orbital floor. A long-term follow-up ranged from 2 to 15 years. The aim of this study was to present a certain number of cases with an interesting pathologic tumor condition showing peculiar behaviors; the management of these cases was a challenge to our surgical experience.

Proliferative activity in oral carcinomas studied with Ag-NOR and electron microscopy.

This study was conducted on 61 patients (27 males and 34 females). The age ranged from 27 to 81 years (mean 54 years). All suffered from oral squamous cell carcinoma and were treated by surgery and deep X-ray therapy (DXT). The UICC and TNM classification and staging recommendations were used for evaluation of the patients. All sections were stained with Ag-NORs stain for examination of the proliferative activity of the squamous cell carcinomas. Biopsies were also taken from another 6 cases--3 cases with normal striated muscle and 3 cases from normal oral mucosa--and served as controls. Statistical studies of Ag-NOR scores were classified into 3 scores: the p values of score I (ANOVA test) were .0001, score II (ANOVA test) was .0001, and score III (ANOVA test) was 06. Both scores I and II were highly significant and score III was significant. Electron microscopy (EM) showed tumor cells with irregular shape and size and with remarkable division of nuclei and chromatin clumps emarginated toward nuclear membrane, and some cases showed chromatin condensed at one pole of the nucleus. Few mitochondria with dilated cristae (?) and abundant rough endoplasmic reticulum (RER) were observed. Few apoptotic changes were noted. This study showed a high proliferation in poorly differentiated squamous cell carcinomas. The amount of Ag-NOR in poorly differentiated squamous cell carcinomas was a prognostic factor and represented an unfavorable prognostic feature in squamous cell carcinoma of the oral mucosa.

Posttraumatic missile injuries of the orofacial region.

Iraq became the world's battlefield for terrorist attack to the victims by different types of weapons of missile including explosive cars, explosive belt, fragments, rifle bullets, and handgun bullets. This situation in Iraq has been present for the last 3 years. As surgeons, we cannot influence the surge of this violence, but we are surely called upon to care for its victims. Missile injuries to the orofacial region have special features that provide the surgeon with multiple medical and surgical challenges when dealing with these injuries. This study include 140 patients who were treated in the maxillofacial unit, hospital of specialized surgery, in Medical City, Baghdad, during a period of 2 years; we had 28 women and 112 men, with ages ranging from 9 to 60 years (mean, 34.5 years), suffering from posttraumatic orofacial deformities. Deformities of the face as a complication of missile injuries were classified as bone loss, soft tissue loss, combined bone and soft tissue loss, and others (sinus tracts and poor scars); 62 patients (44%) had bone loss, 45 (32%) had soft tissue loss, 9 (6.4%) had combined bone and soft tissue loss, and 22 (15.7%) had other deformities.

Study of antiapoptotic gene of oral carcinoma by using Bcl-2 oncogene.

The present study was addressed to find out the expression of Bcl-2 proto-oncogene in tumor tissue derived from 24 patients with malignant oral carcinoma and oral mucosa from the same patients served as control and showed a cytoplasmic pattern of Bcl-2 immunoreactivity in basal cell layer. Fourteen of 24 (58.3%) of oral carcinoma and four adenocystic carcinoma expressed positive Bcl-2 oncogene. Well-differentiated squamous cell carcinoma showed absence of immunoreactivity. No statistically significant correlation could be demonstrated between Bcl-2 immunoreactivity and the age or sex of the patients, tumor size, and lymph node metastasis. A direct correlation between Bcl-2 immunoreactivity in G2 and G3 was statistically significant (P < 0.05). Patients with absence of or low (scores 0 or 1) Bcl-2 immunoreactive tumors manifested poorer overall survival rate in comparison with patients with moderate or high (scores 2 and 3) Bcl-2 expression, but the difference was not statistically significant. Tumors exhibited three different expressions of Bcl-2 (weak, moderate, and strong positive), compared to the mucosa of some patients affected by these tumors. No correlation was found between the histopathology of the tumors, mucosal expression, and degree of Bcl-2 expression. We propose from this study that overexpression of Bcl-2 proto-oncogene acts as a strong antiapoptotic in both squamous cells and adenocystic carcinoma may be an important molecular event on oral carcinoma to make these tumors resistant to radiotherapy and chemotherapy.

Ultrastructural studies of jaw lymphomas and apoptosis.

Research on ultrastructural cytopathological changes and apoptosis that occur in jaw lymphoma were done by using electron microscopy and ground sections. The author described this tumor in 1977-1978 as a highly malignant and lethal condition affecting children between 2 and 8 years (mean age 5 years). A duration of illness between 2 and 3 weeks is common and with a general condition of severe toxicity, anemia, and high body temperature. Clinical and pathological features of 24 children with jaw lymphoma seen in the Maxillofacial Unit, Surgical Specialized Hospital, Medical city, Baghdad, are described. Thirteen males and 11 females were included, with a death rate at 91.1%. The morphological characteristics were examined by ground sections. Lymphoblastic lymphoma features were observed and apoptotic changes were seen in some of the cells. Electron microscopy showed a high number of mitotic figures and lymphoblast transformation to plasma cells with high nucleo-cytoplasmic ratio. Some cells had double nuclei and some nuclei were more convoluted. Apoptotic changes were seen in some cells; chromatin clumps aggregated near the nuclear membrane. Cytoplasmic processes and mitochondria showing degeneration and virus-like particles were seen in both nuclei and cytoplasm. The presence of a high mitotic figure with active oncogenic virus growth and reduced apoptosis is a poor prognostic feature in jaw lymphoma.

Periorbital and orbital malignancies: methods of management and reconstruction in Iraq.

Orbital cancer is rare, and in this study, few cases are reported consisted of 16 patients (nine female, seven male). Age ranged from 9 months to 75 years. Tumor types were squamous cell carcinoma, basal cell carcinoma, conjunctival squamous cell carcinoma, retinoblastoma, fibrosarcoma, and ectopic mixed tumor in two, one, two, one, one, and one patients, respectively, in addition to eight patients with jaw lymphoma involving the orbit, out of 24 patients reported by us. Eight patients were treated surgically with adjuvant postoperative radiotherapy, whereas eight patients with lymphoma treated with combination chemotherapy (vincristine, Adriamycin, cyclophosphamide, methotrexate, and prednisolone), the survival rate was very poor. Follow up ranged from 1 to 5 years. Surgery consisted of complete excision of orbital content (exenteration) with or without partial orbitectomy in four patients and wide excision of the tumor in four patients. Reconstruction of the defect was accomplished using various local skin flaps and temporalis muscle flap was used for augmenting the orbit in the four exenterated patients. No complications were encountered. Survival rate was quite good except for patients with lymphoma with 91.9% mortality. There is no single best method for reconstruction of the periorbital and orbital defects left after tumor resection, and different flaps applied for reconstruction had given satisfactory results related to the type and complexity of the deformity. Temporalis muscle flap in this study had proved to be versatile and highly reliable flap in terms of bulk and vascularity for blocking the orbit. The aim of this study was to show our experience in the management of these cases with minimum surgical morbidity and deformity.

Evaluation of immediate phase of management of missile injuries affecting maxillofacial region in iraq.

In the past two years Iraq was, and still is, subjecting to a confluence of conventional war, civil unrest, guerrilla and terrorist attacks as well as an increasing crime rates. This study evaluates the immediate phase of management of 100 patients suffering from missile injuries to the maxillofacial region. Patients were treated in the maxillofacial unit in the Specialized Surgeries Hospital Medical City, Baghdad during one year (from 2003 to 2004). We had 79 men and 21 women. Age ranged from three to 72 years (mean 37.5 years). The majority of injuries were caused by rifle bullets (49%) followed by fragments (29%), handgun bullets (15%), airgun pellets (6%), and shotgun (1%). Injuries consisted mainly of mandibular fractures found in 56 patients. Urgent airway management was needed in (27%) of patients. Nineteen patients were presented with active bleeding which would not stop without intervention. Most entrance and exit wounds as well as retained missiles were located in the cheek (54.8%, 39.4%, and 27.5% respectively). There were three mortalities due to complications related to head injury. Distribution of missiles used in any conflict reflects the type of this conflict, the prevailing local conditions, and the technological efficiency of weapons used by the opposing teams. Particularly challenging are missile injuries that involve the face, not only because of problems with reconstructing bone and soft tissue defects but also because of emergent problems with airway obstruction and neurovascular compromise.

Apoptotic changes of Middle East jaw lymphoma.

Jaw lymphoma a highly malignant tumor affects children between two and eight years, duration of illness between two and three weeks, and the general condition of severe toxicity, and the death rate is 91.9%. The aim of this cellular study is to show the apoptotic changes associated with these tumors. Twenty-four children, 13 boys and 11 girls, were reported with jaw lymphoma and studied for apoptotic detection of the tumor through morphological assessment by using ground section and electron microscopy. Ground section shows lymphoblastic lymphoma, darkly-stained of ribonucleic acid, also apoptotic changes seen in some of the cells. Electron microscopy showed high mitotic figures, lymphoblast transformed to plasma cell, high nucleocytoplasmic ratio, some cells showed double nuclei, some nuclei are crested in shape or convoluted, degenerative changes seen in some of the cells, chromatin clumps near the nuclear membrane, mitochondria showing homogenous and degenerative changes, virus like particles seen in this nucleus and cytoplasm. The presence of low-level of apoptosis is a poor prognostic feature of jaw lymphoma due to homogeneity and degenerative changes of the mitochondria and disruption of the cell surface.