Panfacial Fractures

Dr Sunil Sidana BDS,MDS,MFDSRCS(Eng)

MGM Dental College and Hospital

Learning Objectives

What is Panfacial Fractures When to treat How to plan Where to Start

Panfacial Fractures

It typically involves the midface in combination with fracture of the mandible and frontobasilar region

But often used to describe complex fractures involving the midface and only one of the other anatomic regions

Some define as it involving the upper, middle and lower one third of face

A 30 yr old Lady is brought to the A&E after she met with the RTA. She was driving at 50 mph and the car collided with a standing bus.

What will you do?

Primary AssessmentAirway with cervical spine controlBreathing with ventilationCirculation with control of bleedingDisability Exposure

After the initial assessment, what can be reasons he may have to be taken to theatre immediately.

Airway compromise Control Hemorrhage Close Open wounds Coincident surgical procedures

To stabilize the patient

What else do you want to do

Rule out concomitant injuries Concomitant injuries in patients with panfacial fractures. Follmar KE et al Injury Oct 2007 Opthalmology consultation Consider Tracheostomy Do a detailed clinical examination Assess soft tissue loss Assess bone loss Take photographs Take impressions for study models Prepare splints and custom arch bars Radiographic studies

1 2

3 4

3D CT Scan

Goals of treatment

Restore form and function Restore the buttresses of the face Restore facial architecture along 3

planes – height, width and projection

Buttresses of the face

Vertical Horizontal Coronal Sagittal

Buttresses of the face

VerticalNasomaxillaryZygomaticomaxillaryPterygomaxillary

Buttresses of the face

Horizontal Superior rim Inferior rim Alveolar process

Buttresses of the face

Horizontal buttress in sagittal plane

Frontal bone

Zygomatic arch

Alveolar process

Body of mandible

Vertical height

Nasomaxillary buttress Zygomaticomaxillary buttress of midface Posterior height of mandible

Facial width

Upper face Nasoethmoid complex centrally Frontal bar and zygomatic arch laterally Lower face Palate and arch of mandible from angle

to angle

Projection

Upper face Frontal bar, zygomatic arch and

nasomaxillary complex Lower face From angle to symphysis

How are facial width and facial projection related

Inversely

What is the shape of zygomatic arch Is it rounded

Or Is it flat

Flat posterolaterally

Should we treat it early or late

Early

Advantages of treating early

Reduces the incidence of postoperative infection

Maintains soft tissue expansion Prevents latent cosmetic and functional

deficits

Disadvantages of treating late Carr and Mathog believe bone healing

beyond 3 weeks is in a “grey stage”—the edges of the fragment begin to absorb and remodel, which makes it very difficult to obtain anatomic reduction. This can lead to bone malunion, delayed union, nonunion, and bone defect.

Carr RM, Mathog RH: Early and delayed repair of orbitozygomatic complex fractures. J Oral Maxillofac Surg 55:253,1997

Also delaying treatment can create a double insult to damage and contused soft tissue and skin. Panfacial Fractures: Analysis of 33 Cases

Treated late E Ellis III et al JOMS 2007

The study highlights the difficulties in treating patients with delayed panfacial fractures

Untreated or Inadequately treated

What is the optimal time to treat

As early as possible may be within 24 hours or maximum within 3-4 days

Surgical approach to panfacial fractures Five Coronal Upper and lower gingivobuccal sulcus incision Retromandibular/preauricular Subciliary/transconjunctival

Comprehensive management of pan-facial fractures. Manson PN, Clark N, Robertson B, Crawley WA.

J Craniomaxillofacial Trauma, 1995

Where to start

Sequences

Top to bottom Bottom to top Inside to outside (centrifugal) Outside to inside (centripetal) Combination Less than systematic approach

SEQUENCE – I : BOTTOM TO TOP

KILLEY APPROACH

– CONDYLE #

– OTHER MANDIBULAR #

MIDFACE #

Zide and Kent 1983; Hayward and Scott 1993

Correct reconstruction of the mandible, including condylar fractures, is considered to be a crucial factor for three-dimensional midface reconstruction (Zide and Kent 1983; Hayward and Scott 1993).

SEQUENCE – II : TOP TO BOTTOM

GRUSS APPROACH

OUTER FRAME– ZYGOMATIC ARCH– ZYGOMA– FZ

INNER FACIAL FRAME– NOE COMPLEX

INTERNAL ORBIT

LE-FORT I

IMF

MANDIBLE

Top to bottom

Merville agreed that sequencing reduction should proceed from “top to bottom” if the NOE region was involved in panfacial fractures

Merville L: Multiple dislocations of the facial skeleton. J MaxillofacSurg 2:187, 1974

Gruss and Phillips advised reduction of zygomatic arch and malar projection as a first step in treatment, to re-establish the “outer facial frame,” and provide upper facial width and projection before NOE, maxillary, and mandibular reconstruction

1.Gruss JS, Van Wyck L, Phillips JH, Antonyshyn O. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. 1990; 85:878-890

Outside to Inside

INITIAL RESTORATION OF ZYGOMATIC ARCH AND FZ SUTURE LINE – ANTEROPOSTERIOR AND TRANSVERSE FACIAL WIDTH

UPPER INNER FACIAL FRAME , INFRAORBITAL RIM AND NASOETHMOID MARGIN

LOWER FACIAL FRAME- ESTABLISHING CORRECT OCCLUSION AND COMPLETING REPAIR AT ANTERIOR MAXILLARY BUTTRESSES

Outside to Inside and Top to Bottom

Key to reduction of zygoma

Lies at the lateral wall of the orbit

Inside to Outside

Manson and Markowitz 1988 put emphasis on initial reconstruction of nasoethmoid region following reestablishment of the occlusion

Nasoethmoid area is noted to be the key landmark in establishing central midfacial width

Panfacial fractures, organisation of treatment, Manson and Markowitz,Clin Plastic Surg 1989

Sequence III- Bottom to top to middle MANSON & KELLY APPROACH

SUBCONDYLAROTHER MANDIBULAR #IMFFRONTAL #NE #ZYGOMATIC ARCHORBITLE-FORT I

Sagittal/Parasagittal fractures of Maxilla

For cases where the maxilla and mandible have fractures that interrupt the geometry of the dental arches, Kelly et al suggested reducing and stabilizing the hard palate as a guide for mandible reconstruction

Sequence of operative repair in panfacial injuries

Peter Ward Booth, McMohan 2003

Fixation of the sagittal fractures of maxilla and mandible

Fixation of mandibular condyle

Reassembling the upper facial subunit

Midfacial repair starts at the least injured part of the orbits

Buttress reconstruction

Bone grafting and canthopexy

When will you bone graft in panfacial fractures

greater than 5 mm bone gaps

Last but not the least

Close from inside to outsideReattach periosteum, fascia, muscleMedial and lateral canthal tendon

Soft tissue repair “ the fourth dimension”

Kelly KJ, Manson PN, Vander Kolk CA, et al: Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg 1:168, 1990

Conclusion

Do not forget ABCDE Rule out concomitant injuries Treat as early as possible Plan out your sequence At the end drape the soft tissue

properly.

References

1. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort fracture treatment (organization of treatment for a panfacial fracture). J Craniofac Surg. 1990; 1:168-178.

2. Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: The importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. 1999; 103:1287-1306.

3. Wenig BL. Management of panfacial fractures. Otolaryngol Clin North Am. 1991; 24:93-101.

4. Jack JM, Stewart DH, Rinker BD, Vasconez HC, Pu LL. Modern surgical treatment of complex facial fractures: A 6-year review. J Craniofac Surg. 2005; 16:726-731.

Thank you