Managing Low-Velocity Mandibular Gunshot Wounds: An Institutional Review and the "FLOSS" Severity Scoring System

Management of mandibular ballistic trauma is poorly delineated, given the variable injury complexity. This study examines surgical outcomes and presents a novel scoring system to define and guide the management of low-velocity ballistic mandibular fractures.

A retrospective chart review was performed from 2015 to 2022 to collect data on patients who suffered ballistic mandibular fractures. Computerized tomography facial bone scans were analyzed to determine a mandible severity scoring based on the following "F.L.OS.S." variables: fracture description (F), location of fracture (L), other surrounding fractures (OS), and soft tissue involvement (S).

Sixty-six patients suffered handgun-related mandibular fractures and 54 underwent surgical intervention. The mean FLOSS score was 7.9 for all surgical patients and significantly differed between treatment groups ( P = 0.011). Certain injury-specific variables were significantly associated with higher FLOSS scores including >2 areas of comminution along load bearing, bony gap >10 mm, or intraoral involvement with soft tissue avulsion; however, the degree of displacement, bilateral involvement, or presence of concomitant fractures did not predict higher scores. The types of complications did not significantly vary for total FLOSS score or FLOSS subcategories; the only exception being, an association between bony gap (>10 mm) and hardware exposure ( P = 0.045). Overall surgical complication rate was 26.9% and presence significantly varied between surgical treatments ( P = 0.019); specifically, nonunion was the only significant subcategory ( P = 0.030).

The FLOSS scoring system may be a useful adjunct in defining fracture characteristics that guide appropriate surgical intervention for low-velocity ballistic mandibular injuries.