PMC8407627_01
(Case 1) "Bottom-up, outside-in" sequence, first restoring the occlusal unit, achieving a stable base, followed by reconstruction of rest of the craniofacial skeleton, correcting its widened transverse dimensions. (A-C) Extreme broadening of the mandibular body corrected by compressing splayed apart of the angle regions, restoring its "horseshoe" contour, followed by stable fixation. (I-O) Disimpaction, reduction, and fixation of the laterally rotated maxillary halves. (P-AF') Approximation and fixation of comminuted fractures of zygoma, orbital floor and infraorbital rim, frontal bone, and naso-orbito-ethmoidal regions
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F1
A 31-year-old patient sustained severe pan-facial injuries when his motorbike skidded off the road and he drove full speed into an electrical pole, which struck him at the center of his face [Figures 1-4]. A "bottom-up, outside-in" surgical approach was employed, first restoring the occlusal unit comprising the mandible and maxilla, thereby achieving a stable base, followed by reconstruction of the rest of the craniofacial skeleton, successfully correcting its abnormally widened transverse dimensions [Figure 1]. The displaced midline fracture of the mandibular symphysis with overriding fracture ends was reduced first [Figure 1a and b]. Continuity at the inferior border, as well as the lingual aspect, was carefully checked followed by stable fixation using titanium minibone plates and screws, using occlusion as the guide [Figure 1c-h]. Disimpaction was carried out using Rowe's disimpaction forceps [Figure 1i and j]. The maxillary midline split was reduced, the two laterally rotated halves brought together into apposition and alignment, teeth were brought into occlusion using the segmental arch bars to guide the final fracture alignment, followed by fixation at the midline at the alveolar base, as well as along both the lateral pyriform rims [Figure 1k-o]. The fractured right and left zygomas and inferiorly displaced orbital floors and infraorbital rims were reduced and fixed using microplates and screws, thus restoring volume and integrity of the orbits [Figure 1p-x]. The comminuted fracture of the frontal bone was then reduced, re-approximated, and fixed using microplates and screws [Figure 1Y-AA']. Nasal packing was carried out, and general anaesthesia (GA) was reversed with the tracheostomy tube retained in place [Figure 1AB'-AD'].
(Case 1) Pan-facial injuries sustained by driving into an electrical pole. (a-h) "Panda facies," severe facial broadening and flattening of profile, displaced midline fractures of maxilla and mandible with splaying apart of the dental arches and a wide mid-palatal split. (i-j) Noncontrast computed tomogram showing an unusual fracture pattern with splitting the facial skeleton at the midline and flaring of the two halves laterally. Loss of mandibular morphology, separation and lateral rotation of the two halves of the maxilla, comminuted fracture of the frontal bone and naso-orbito-ethmoidal complex
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F2
A 31-year-old patient sustained severe pan-facial injuries when his motorbike skidded off the road and he drove full speed into an electrical pole, which struck him at the center of his face [Figures 1-4]. In addition to multiple abrasions and lacerations, the patient exhibited extreme facial widening, impaction of the mid-face, circumorbital edema, and ecchymosis, producing a classical "panda facies" as well as the typical "dish-face" deformity [Figure 2a-d]. The patient was tracheotomized due to severe disruption of the nasal and midline maxillofacial structures, with airway compromise [Figure 2e and f]. Segmental arch bars were fixed in all four quadrants, after taking impressions and preparing models for the fabrication of palatal and lingual splints [Figure 2g and h]. There was splitting of the facial skeleton at the midline and splaying apart of the two halves laterally, resulting in extreme facial widening [Figure 2i]. Axial sections too showed the midline split of the mandible with outward rotation of the body regions and wide splaying apart of the angle regions bilaterally, converting the normal "horseshoe" shape of the lower jaw into a "V" shape [Figure 2j]. Axial sections of the maxilla showed wide mid-palatal split with the separation of two halves of the maxilla, associated with disruption of the NOE complex [Figure 2k].
(Case 1) (a-d) Appearance on the 10th postoperative day showing correction of broadened transverse facial width with restoration of ideal facial symmetry, contour, dimensions, and occlusion. (e-h) Radiographs showing restoration of transverse width of the craniomaxillofacial facial skeleton and good approximation of the fracture fragments. (i-l) 3 months' postoperative appearance showing well-healed operated sites, i.e., normal projection of the face in the anteroposterior, vertical, and transverse dimensions. (m-p) Two-year postoperative photographs confirming stability of results
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F3
A 31-year-old patient sustained severe pan-facial injuries when his motorbike skidded off the road and he drove full speed into an electrical pole, which struck him at the center of his face [Figures 1-4]. Postoperative recovery was smooth and uneventful with nil complications [Figure 3]. Appearance on the 10th day following surgery showed successful correction of the broadened transverse facial width with restoration of ideal facial symmetry, contour, and dimensions [Figure 3a-c]. There was achieved successful restoration of occlusion with successful correction of the outward splaying of the displaced quadrants and good healing of all operated sites [Figure 3d]. Postoperative radiographs showed successful restoration of correct transverse width of the craniomaxillofacial facial skeleton, good alignment, and approximation of the fracture fragments of the pan-facial complex with the fixation implants in situ [Figure 3e-h]. Three months' postoperative appearance showed well-healed operated sites, i.e., normal projection of the face in the anteroposterior, vertical, as well as transverse dimensions [Figure 3i-l]. The patient was followed up for 2 years, and there was evidence of good bony union at all the fracture sites with stable results with no residual deformity of functional deficits, thus confirming excellent esthetic and functional outcomes of the "bottom-up and outside-in" surgical management of the extensive pan-facial injuries [Figure 3m-p].
(Case 1) (a) Postoperative noncontrast computed tomogram (axial sections) showing precise reduction and stable fixation of displaced symphyseal fracture, with the achievement of normal "horseshoe" shape of mandibular corpus. Precise alignment of the right and left maxillary halves with approximation at the midline; fixation and bony union of the mid-palatal split and of multiple fracture fragments of the naso-orbito-ethmoidal complex. (b) Three-dimensional images showing restoration of correct craniomaxillofacial skeletal morphology and transverse dimension, which had been grossly deranged by the force of the injury
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F4
A 31-year-old patient sustained severe pan-facial injuries when his motorbike skidded off the road and he drove full speed into an electrical pole, which struck him at the center of his face [Figures 1-4]. Postoperative NCCT of the craniomaxillofacial region taken a year following surgery showed restoration of continuity of the mandible with precise reduction and stable fixation of the grossly displaced symphyseal fracture, with evidence of bony union [Figure 4a]. The reduced and fixed nasal bones retained their morphology with good union of the multiple fracture fragments of the NOE complex. 3-D reformatted images showed restoration of the correct craniomaxillofacial skeletal morphology and shape, in particular, the transverse dimension, which had been grossly increased by the force of the blow which had split the facial skeleton with wide splaying apart of the right and left halves [Figure 4b].
PMC8407627_02
(Case 2) (a-c) Grievous craniomaxillofacial injuries sustained from a self-inflicted gunshot wound. The bullet entered below the chin and exited just above the nasal bones, disrupting the frontal sinus. (d) Noncontrast computed tomogram revealed a comminuted fracture of the maxilla with a mid-palatal split and splaying apart of the two halves; anterior maxillary dentoalveolar comminution; mandibular symphyseal fracture with displacement and distraction of the two halves; fractured nasal bones and comminution of anterior table of the frontal sinus
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F5
A 25-year-old patient sustained grievous craniomaxillofacial injuries from a self-inflicted gunshot wound [Figures 5-7]. The bullet had traversed upward disrupting the mandibular symphysis, and then, it had perforated the center of the tongue and shattered the hard palate, anterior maxilla, and the naso-ethmoidal regions, before fragmenting and exiting through the anterior wall of the frontal sinus [Figure 5a-c].
(Case 2) (A-J) Lacerated tongue sutured in layers, displaced symphyseal fracture, and outwardly splayed maxillary halves reduced and fixed. (K-N) Comminuted fractures of frontonasal regions re-approximated and fixed using microplates, screws, and titanium mesh. (O-Y) Widening and collapse of nasal bridge and traumatic telecanthus managed by closed medial canthopexy, with the help of two 3-hole microplates to compress the splayed nasal bones together. (Z-AA') Good postoperative recovery, patient de-tracheotomised on the 10th day. (AB') Residual palatal fistula planned for secondary closure
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F6
A 25-year-old patient sustained grievous craniomaxillofacial injuries from a self-inflicted gunshot wound [Figures 5-7]. Open reduction and internal fixation using the "bottom-up, outside-in" approach was carried out [Figure 6]. After thorough debridement of the wounds and removal of all nonviable tissues including small bony splinters, the severely lacerated and profusely bleeding tongue, which had been perforated by the traversing bullet, was sutured in three layers [Figure 6a and b]. The symphyseal fracture was fixed first so as to achieve a stable base [Figure 6c-e], followed by fixation of the maxilla at the zygomaticomaxillary buttresses bilaterally [Figure 6f-i]. The palatal split was checked for adequate reduction and coaptation, and torn palatal mucosa was closed with vicryl 3-0 sutures [Figure 6j]. Comminuted fractures of the nasal bones and anterior table of the frontal sinus were reduced, and the frontonasal suture regions re-approximated and fixed using microplates and screws [Figure 6k-m]. A persisting defect at the anterior table of the frontal bone was bridged using a titanium mesh [Figure 6n]. An 18-gauge needle was inserted percutaneously at the deepest portion of the root of the nose on its lateral aspect and then passed transnasally to the opposite side [Figure 6o-q]. The wire was drawn through the middle hole of a 3-hole microplate; the plate was closely adapted against the skin overlying the left nasal bone and then drawn through the lower hole of the same plate [Figure 6r]. The same procedure was repeated on the right side and a second 3-hole microplate was adapted on this side, and the wire ends were twisted together over the middle and lower holes of the plate [Figure 6s-v]. These external microplates served to compress the spayed apart of the nasal bones together, thus narrowing of the nasal bridge [Figure 6Z-AA']. Postoperative recovery was good and the patient was de-tracheotomized on the 10th day following surgery [Figure 6w-y]. At the time of discharge, a residual palatal fistula was noted in the midline, measuring 1 cm in diameter, which was planned for secondary closure after 3-6 months [Figure 6AB'].
(Case 2) (a-d) Postoperative noncontrast computed tomogram showing restoration of ideal skeletal morphology and transverse dimensions. (e-i) 5 months' postoperative appearance showing good restoration of facial esthetics with nil functional deficits. (j) Satisfactory restoration of occlusion and masticatory efficiency. (k and l) A large residual palatal defect causing an oronasal communication, associated with nasal regurgitation. (m-x) Secondary reconstruction using a robust anteriorly based, dorsal pedicled tongue flap, achieving complete closure of the palatal defect, with nil donor site morbidity
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F7
The force of the impact had split the upper and lower lips and shattered both the jaws at the center, with comminution as well as flaring apart of the right and left halves, resulting in severe facial splaying and widening [Figure 7].
PMC8407627_03
(Case 2) (a-d) Postoperative noncontrast computed tomogram showing restoration of ideal skeletal morphology and transverse dimensions. (e-i) 5 months' postoperative appearance showing good restoration of facial esthetics with nil functional deficits. (j) Satisfactory restoration of occlusion and masticatory efficiency. (k and l) A large residual palatal defect causing an oronasal communication, associated with nasal regurgitation. (m-x) Secondary reconstruction using a robust anteriorly based, dorsal pedicled tongue flap, achieving complete closure of the palatal defect, with nil donor site morbidity
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F7
The force of the impact had split the upper and lower lips and shattered both the jaws at the center, with comminution as well as flaring apart of the right and left halves, resulting in severe facial splaying and widening [Figure 7].
(Case 3) (a-i) Blow from an iron cattle tethering peg, producing lacerations of lips, fracture avulsions of anterior dentoalveolar segments, parasymphysis fracture, and maxillary fracture with a paramedian split. (j-l) Widening of lower half of face from outward splaying of the two halves of maxilla and mandible. (m-p) Noncontrast computed tomogram showing comminuted parasymphyseal fracture, overriding of central fracture ends and flaring out of the angle regions with broadening of the mandibular body; a mid-palatal split with separation of the two halves, producing transverse widening of the maxillofacial skeleton
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F8
A 35-year-old male, who was seated next to the driver in a four-wheeler vehicle, was struck at the center of his face by an uprooted, heavy cattle tethering peg, which had swung in on its rope, through the passenger-side window [Figures 8-10]. I fracture of the maxilla with a paramedian split and lateral rotation of its right and left halves were accompanied by fracture avulsions of the upper and lower anterior dentoalveolar segments [Figure 8a-f]. Immediate primary soft tissue closure was carried out, and the patient was thereafter planned for surgery under GA for the management of the maxillofacial fractures [Figure 8g-i]. There was considerable widening of the lower half of the face, owing to the splaying outward and apart of the two halves of both, the maxilla and mandible, caused by the force of the medially directed impact by the heavy metal object [Figure 8j-l].
(Case 3) (a-d) Exposure of displaced and comminuted parasymphyseal fracture. (e-m) Pressure applied against flared out angle regions bilaterally, disimpacting the overlapping fragments anteriorly, followed by fixation. (n and o) Precise realignment and reconstruction of the disrupted alveolar process of mandible confirmed intraorally. (p-s) Laterally rotated right and left maxillary halves reduced, brought into apposition closing the palatal split, followed by fixation. (t) Restoration of correct maxillary and mandibular alveolar arch morphology and dimensions, occlusion, and interarch relationships
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F9
A 35-year-old male, who was seated next to the driver in a four-wheeler vehicle, was struck at the center of his face by an uprooted, heavy cattle tethering peg, which had swung in on its rope, through the passenger-side window [Figures 8-10]. The "bottom-up" surgical sequence was employed to manage the multiple maxillofacial fractures [Figure 9]. An extreme overriding of the fracture ends at the center with outward rotation and widening of the body region was evident [Figure 9a-d]. The free triangular fragment of the bone was repositioned, and fixation was carried out using two minibone plates and screws [Figure 9e-h]. One long plate was used to stabilize the inferior border and another one was placed along its lateral surface, bridging the multiple fragments [Figure 9i-m]. Precise realignment and reconstruction of the disrupted alveolar process of the mandible were confirmed intraorally [Figure 9n and o]. The laterally rotated right and left maxillary halves were reduced, brought into apposition with one another, thus closing the palatal split, followed by fixation using one curved miniplate across the midline below the base of the pyriform rims, using occlusion as a guide [Figure 9p-s]. Restoration of the correct maxillary and mandibular alveolar arch morphology and dimensions, occlusion, and inter-arch relationships was successfully achieved [Figure 9t].
(Case 3) (a-d) 3 months' postoperative appearance showing correction of widened maxillofacial region and achievement of good esthetic and functional outcomes. (e-h) Patient rehabilitated with removable partial dentures, with restoration of good masticatory efficiency. (i) Non contrast computed tomogram showing re-establishment of pre-trauma status of transverse maxillofacial dimensions. (j) Precise restoration of mandibular and maxillary continuity and integrity, with restoration of the "horseshoe" shape of the mandible and complete closure of the maxillary mid palatal split
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F10
A 35-year-old male, who was seated next to the driver in a four-wheeler vehicle, was struck at the center of his face by an uprooted, heavy cattle tethering peg, which had swung in on its rope, through the passenger-side window [Figures 8-10]. There was achieved successful restoration of ideal facial width, morphology, contour, and projection, resulting in an excellent esthetic and functional outcome, with nil early or late complications encountered [Figure 10a-d]. The patient was rehabilitated with well-fitting upper and lower removable partial dentures, with restoration of ideal occlusion and good masticatory efficiency [Figure 10e-h]. NCCT of the craniomaxillofacial region showed successful correction of the deranged and grossly widened skeletal structure with the re-establishment of pretrauma status of transverse, anteroposterior, and vertical maxillofacial dimensions [Figure 10i]. Precise restoration of mandibular and maxillary continuity and integrity was achieved, with restoration of the normal "U" or "horseshoe" shape of the mandibular corpus and complete closure of the maxillary mid-palatal split [Figure 10j].
PMC8407627_04
(Case 4) Pan-facial injuries caused by blow on the face with a bamboo stick. (a) Splitting and comminution of bones at the center, with lateral flaring out, producing extreme facial widening. (b) Noncontrast computed tomogram showing comminuted and displaced fracture of mandibular symphysis, with overriding of central fractured ends and flaring outwards of the body and angle regions, comminuted fracture of nasomaxillary complex, frontal bone, and Le Fort III fracture of the maxilla are also evident. (c) Axial sections showing distortion of mandibular shape from "horseshoe" to "V" shape
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F11
A 31-year-old patient sustained pan-facial injuries from a blow with a bamboo stick, at the center of his face, by an assailant [Figure 11 and 12]. Splitting and comminution of the bones of the central craniomaxillofacial region resulted in their lateral flaring out, causing an extreme widening of the face [Figure 11a]. NCCT of the craniomaxillofacial region showed a severely comminuted and displaced fracture of the mandibular symphysis, with extensive fragmentation of the dentoalveolar complex [Figure 11b]. Axial sections [Figure 11c] showed the symphyseal fracture of the mandible accompanied by a lateral rotation of the body regions and outward flaring of the angle regions bilaterally, distorting its shape from a "horseshoe" to a "V" shape.
(Case 4) (a) 2 weeks' and 3 months' postoperative appearance showing significant improvement in facial esthetics due to the resolving edema and successful surgical correction of the extreme transverse facial widening that had been caused by the trauma. (b) Radiographs showing restoration of ideal facial skeletal morphology and symmetry and well-aligned pan-facial fracture fragments with the implants in situ. (c and d) Noncontrast computed tomogram showing precise alignment, stable fixation and reconstruction of the disrupted craniofacial bones to their proper shape and contour
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F12
A 31-year-old patient sustained pan-facial injuries from a blow with a bamboo stick, at the center of his face, by an assailant [Figure 11 and 12]. The pan-facial fractures were effectively managed using the "bottom up-outside in" approach, with excellent restoration of the facial width, height, and projection, to the pretrauma status, resulting in gratifying esthetic and functional outcomes [Figure 12]. Significant improvement in the facial esthetics was observed postoperatively [Figure 12a], both, due to the resolving edema as well as successful surgical correction of the extreme transverse facial widening that had been caused by the trauma. Radiographs showed restoration of an ideal facial skeletal morphology and symmetry and well-aligned pan-facial fracture fragments with the implants in situ [Figure 12b]. NCCT of the craniomaxillofacial region showed precise alignment, stable fixation, and establishment of continuity at the various fracture sites and reconstruction of the disrupted craniofacial bones to their proper shape and contour [Figure 12c]. Axial sections showed successful realignment and fixation of the mandible, maxilla, nasomaxillary complex, and calvarial bone [Figure 12d].