Management of Panfacial Fractures 

The management of panfacial fractures has undergone several changes in the last decade. Plate-and-screw fixation has completely revolutionized the sequence with which panfacial injuries can be managed. The "inside-out, bottom-to-top" approach has been the guiding principle in the management of panfacial trauma. With the advent of rigid fixation, midface reconstruction can precede the fixation of the mandible if adequate bony keys or pillars are restored to ensure proper maxillary positioning. See the images below.

Panfacial injuries involve trauma to the upper, middle, and lower facial bones. Because such injuries are commonly associated with multisystem injury or polytrauma, treatment often requires a team approach.^{[1, 2]} After the patient is stabilized, the maxillofacial surgeon’s goals are early and total restoration of the form and function of the patient’s face.^[1]

For information on treatment of more isolated facial fractures, see eMedicine articles Mandible Fractures, General Principles and Occlusion; Mandible Fractures in Children; Maxillary Zygomatic Fractures; and Nasal Fracture Reduction. For additional specific fractures, see related topics in the Facial Fractures section of the Plastic Surgery journal and the Trauma section of the Otolaryngology and Facial Plastic Surgery journal.

Panfacial fractures can be caused by various traumatic injuries to the face. According to a 2008 retrospective analysis, the most common causes of facial fractures are assault (36%), motor vehicle collision (32%), fall (18%), sports (11%), occupational (3%), and gunshot wound (2%).^[3] Motor vehicle collisions and gunshot wounds were found to be significant predictors of panfacial fractures.^[3]

In the treatment of a patient with multiple maxillofacial injuries, differentiating injuries that require immediate operative management from those for which the operation can be delayed is critical.^{[2, 4]} An immediate operation may be indicated to initially stabilize a patient rather than to provide definitive treatment; therefore, those procedures that require more extensive evaluation are delayed to a later date when the patient is systemically stable. Occasionally, the immediate operation can be the definitive procedure. Immediate initial treatment in patients with maxillofacial injuries is indicated when the following are present:

• Airway compromise:^{[5, 6, 7, 8, 9]} Airway compromise is common in persons with severe maxillofacial injuries and may require an immediate operation to temporarily reduce the fractured facial bones encroaching on the airway. A surgical airway may be necessary to facilitate later surgical procedures.
• Severe hemorrhage: Severe bleeding from fractured bony segments also may necessitate immediate surgery to ligate associated major vessels or to reduce the segments and thus control the hemorrhage.
• Large open wounds: Debride and close large open wounds in a layered fashion early. Wounds that are to be used later for access to repair fractures may be closed in a temporary manner.
• Coincidental surgical procedure being performed: Occasionally, patients with multiple injuries undergo surgery immediately by another service to treat a concomitant injury. Performing a complete examination, debriding and stabilizing maxillofacial injuries, and even taking dental impressions while the patient is anesthetized may be advantageous. Impressions are taken for study models and may be used to fabricate surgical splints for use in definitive surgery.

The surgeon presented with such complex maxillofacial injuries should be alert to the potential for both obvious injuries and occult injuries to other systems of the body. The force necessary to create such severe facial injuries is usually significant enough to cause concomitant injury to the central nervous system, chest, abdomen, pelvis, or extremities.

Start with a detailed systemic examination, using the advanced trauma life support protocol. Proceed to a written description of all maxillofacial injuries, with drawings of both soft and hard tissue injuries. Photographs are an excellent means of documenting the preoperative soft tissue injuries. Once the patient is stabilized systemically, perform a more thorough systematic maxillofacial examination. The clinical findings should correlate with diagnostic radiographic images.

The indications for surgery in a panfacial trauma are the same as those outlined for each facial unit. Restoration of preinjury facial aesthetics and function is the goal of treatment. Early and total restoration of facial form and function prevents latent cosmetic and functional deficits.

Definitive treatment of maxillofacial injuries can be delayed if the patient has severe, compromising, concomitant systemic trauma. Treatment of facial fractures can be delayed as many as 2 weeks after injury if the fractures do not involve cranial structures.

Operate on patients with neurologic or cranial injuries when they are stable. This allows for correction of blood volume, electrolyte, and nutritional deficits while giving the surgeon time for an accurate evaluation and proper planning of the surgical procedure.

The resolution in facial edema during this time allows for more accurate clinical evaluation and simplifies the surgical procedure. Necessary radiographic imaging studies and consultations can also be obtained during this time. For more information on imaging studies, see Orbit, Fractures in eMedicine's Radiology journal.