Splitting and Splaying Apart of the Craniomaxillofacial Skeleton by Medially Directed Disruptive Forces of Unusual Etiologies- A Case Series

INTRODUCTION: Extreme forces directed towards the centre of the facial region can produce devastating injuries, with disruption of the mandible, maxilla and naso-orbito-ethmoid complex, with or without frontal bone involvement. The magnitude and trajectory of the force and nature of the impacting object, dictate the degree of displacement and comminution of the craniomaxillofacial skeletal components, as well as the extent of soft tissue loss sustained. DIAGNOSIS & CHALLENGES: To elucidate various challenges faced in the management of four cases of extreme craniomaxillofacial injuries, caused by centrally directed forces of rather unusual etiologies, namely, a traversing bullet, a bamboo rod, a heavy iron cattle tethering peg and a metal electrical pole. In each of the cases, the force of impact resulted in splitting and splaying apart of the facial skeleton, with a resultant increase in its transverse width, and an ensuing severe facial deformity and functional debility. RATIONALE & INTERVENTIONS: A ߢBottom-up, Outside-in’ surgical sequence was employed to carry out reduction, fixation and reconstruction of the deranged maxillofacial skeletal architecture and restoration of the soft tissue morphology. OUTCOMES & LESSONS: The transverse dimensions of the flared out facial frames could be re-established and restored to their pre-trauma status successfully in all the cases, thereby achieving excellent esthetic and functional outcomes. Despite the extensive and serious nature of the injuries sustained, gross residual craniofacial defects, deformities and asymmetries, as well as debilitating functional deficits, could be effectively and successfully averted.