Management of Panfacial Fractures Treatment & Management

  • Author: Kris S Moe, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS  more...
 
Updated: Sep 16, 2015
 

Preoperative Details

Preoperative treatment planning is essential to the success of the case. Obtain information regarding (1) the location and extent of all fractures; (2) the structures injured or involved along the fracture site; (3) the amount of soft tissue loss, including skin, mucosa, and nerve tissue; (4) the extent of bone loss; and (5) the presence of dentoalveolar injury. See the images below.

Large stellate upper lip laceration demonstrating Large stellate upper lip laceration demonstrating comminution of anterior maxilla.
Comminuted zygomatic arch. Comminuted zygomatic arch.

Large bony defects or defects with poor soft tissue coverage are best treated in a delayed fashion with consideration of distant flap reconstruction or grafts. Discontinuity defects can be managed using maxillomandibular fixation (MMF) or internal or external fixation devices. The definitive bone grafting procedure can be accomplished as a primary and a secondary procedure.

Gross loss of teeth may affect the ability to relate the maxilla to the mandible. Loss of posterior teeth may mean loss of vertical dimension, a consideration in prosthetic rehabilitation. This is of great importance in cases involving mandibular condyle fractures. Often, a splint is helpful in these situations to establish proper vertical dimension and posterior vertical height.

Consider the need for autologous grafts intraoperatively (ie, bone, nerve) or alloplastic devices. Submandibular endotracheal intubation may be an alternative to tracheotomy in the surgical treatment of selected patients.[5]

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Intraoperative Details

The key to treatment of panfacial fractures is establishing fixation of stable regions to unstable regions. How the mandibular subcondylar region is addressed has led to the basic philosophies of treatment.

In patients with midface fracture displacement and fracture-dislocation of the mandibular condyles, at least one of the condyles must be anatomically reduced by open reduction in order to obtain proper mandibular positioning.

In patients in whom minimal displacement of the condylar fragments has occurred, clinical judgment must prevail.[14] However, the potential for further displacement of fragments during the process of fracture reduction also must be kept in mind.

Frequently, a traumatic laceration may be used or extended to approach the fracture. In patients in whom the traumatic lacerations do not provide convenient access for bony repair or reconstruction, the surgeon must gain access to the facial skeleton by using the appropriate incisions for the specific bony injuries.

Access to the mid face can be obtained through various incisions; however, a transconjunctival incision, a lateral retrocanthal approach, a precaruncular approach, and an intraoral vestibular incision coupled with a coronal incision provide access to the entire mid face. See the images below.

Coronal approach used to access mid face. Coronal approach used to access mid face.
Coronal access to nasal and medial orbital compone Coronal access to nasal and medial orbital components.

Restoration of the mid face is based on proper reconstruction of the 3 pillars or buttresses of the face. The nasomaxillary (medial) buttress extends from the anterior maxillary alveolus, piriform aperture, and nasal process of the maxilla to the frontal bone. The zygomaticomaxillary (lateral) buttress extends from the lateral maxillary alveolus, to the zygomatic process of the frontal bone, and laterally to the zygomatic arch. The pterygomaxillary (posterior) buttress is a posterior maxilla attachment to the pterygoid plate of the sphenoid bone.

The 2 basic ways to address the treatment sequence for panfacial fractures have traditionally been with bottom-to-top or top-to-bottom techniques. These approaches are described below; however, the basic tenets of treatment are establishing fixation from a stable segment to an unstable segment while maintaining the occlusal relationship.

Bottom-to-top technique

This technique is based on the fact that the mandible can be reconstructed to provide an intact relationship for positioning of the maxilla. The subcondylar region first needs to be treated 1 of 2 ways, either open reduction or closed reduction using external pin fixation devices.

Prior to the advent of plate-and-screw fixation, MMF was required, and concern about telescoping of the segments in the subcondylar region remained.

The mandible can now be reconstructed using plates and screws; therefore, the remainder of the case can be treated as an isolated midface fracture. Positioning of the maxilla, and therefore the mid face, relies on proper seating of the condyle in the glenoid fossa. See the image below.

Mandible stabilized with plate-and-screw fixation. Mandible stabilized with plate-and-screw fixation.

Top-to-bottom technique

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. The collapse of the arch results in inadequate anterior-posterior projection of the body of the zygoma and an increase in facial width.

Reconstruction of the outer facial frame is believed to be key to successful reconstruction. First, reconstruct the outer facial frame (ie, zygomatic arch, zygoma, frontal areas). See the image below.

Fixation of zygoma and zygomatic arch. Fixation of zygoma and zygomatic arch.

Second, reconstruct the inner facial frame (ie, nasoethmoid complex, zygomaticofrontal sutures, infraorbital rim). See the image below.

Fixation of nasoorbitoethmoid component. Fixation of nasoorbitoethmoid component.

Third, reconstruct the maxilla at the Le Fort I level by plating the buttresses. See the image below.

Maxillary fixation at the level of the zygomaticom Maxillary fixation at the level of the zygomaticomaxillary buttress and the piriform rim.

Last, temporary MMF is accomplished followed by open reduction internal fixation (ORIF) of the mandible.

The advantages of the top-to-bottom sequence are that (1) subcondylar fractures can be treated closed and (2) it eliminates the risks of ORIF in the condylar/subcondylar region.

Close soft tissues from the bone or oral cavity outward toward the skin. Close lacerations of the pharynx, tongue, and palate prior to placing the patient in MMF. Thoroughly debride perforating wounds before closure.

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Complications

Panfacial injuries are prone to complications associated with the facial structures involved in the injury. Therefore, consider complications associated with frontal sinus, zygomatic, maxillary, mandibular, nasal, and nasoorbitoethmoid fractures. Complications associated with complex maxillofacial injuries include the following:

  • Neurologic deficits, including motor and sensory (anesthesia, paresthesia) deficits
  • Decrease in posterior facial height
  • Anterior open bite (apertognathia)
  • Increase in facial width: Facial width must be controlled by orientation from cranial base landmarks. [15]
  • Decrease in anterior-posterior facial projection
  • Traumatic telecanthus (See the images below.)
    Traumatic telecanthus secondary to nasoorbitoethmo Traumatic telecanthus secondary to nasoorbitoethmoid fracture. Intercanthal distance is 39 mm.
    Postoperative view of patient, demonstrating norma Postoperative view of patient, demonstrating normal intercanthal distance (33 mm) after resuspension of the medial canthal ligament and fixation of the nasoorbitoethmoid component.
  • Malocclusion [16]
  • Nasal obstruction and deformities
  • Anosmia
  • Blindness

A retrospective study by Bellamy et al indicated that in patients with panfacial fractures, fracture to the upper face is independently associated with a 3.59-fold increase in the risk of death (compared with a 4.06- and 3.46-fold increase for isolated upper and combined upper facial fractures, respectively). The study involved 4540 patients.[17]

See Pathophysiology for complications related to treatment of individual components.

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Outcome and Prognosis

At first glance, panfacial trauma can appear complex and difficult to treat. The actual treatment involves a conglomeration of many smaller procedures that are commonplace in maxillofacial injuries. Adhering to a treatment protocol and treating each fracture as a unit enable the surgeon to obtain reproducibly good results. Development of a step-by-step treatment plan prior to surgery and adherence to the general principles of maxillofacial trauma simplify the treatment of these patients. See the images below.

Postoperative view of patient. Postoperative view of patient.
Postoperative frontal view of patient, demonstrati Postoperative frontal view of patient, demonstrating good facial symmetry.
Postoperative profile view of patient, demonstrati Postoperative profile view of patient, demonstrating good nasal dorsal and zygomatic anterior-posterior projection.
Postoperative view of patient, demonstrating norma Postoperative view of patient, demonstrating normal intercanthal distance (33 mm) after resuspension of the medial canthal ligament and fixation of the nasoorbitoethmoid component.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Facial Fracture.

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Contributor Information and Disclosures
Author

Kris S Moe, MD, FACS Chief, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine

Kris S Moe, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Academy of Otolaryngology-Head and Neck Surgery, North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.

Chief Editor

Deepak Narayan, MD, FRCS Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center

Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Plastic Surgery Research Council, Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, Indian Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

James F Thornton, MD Associate Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Adel R Tawfilis, DDS; David W Kim, MD; Patrick Byrne, MD; and Louie Limchayseng, DMD, FACD; to the development and writing of this article.

References
  1. Wenig BL. Management of panfacial fractures. Otolaryngol Clin North Am. 1991 Feb. 24(1):93-101. [Medline].

  2. Follmar KE, Debruijn M, Baccarani A, et al. Concomitant injuries in patients with panfacial fractures. J Trauma. 2007 Oct. 63(4):831-5. [Medline].

  3. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008 Apr. 60(4):398-403. [Medline].

  4. Catapano J, Fialkov JA, Binhammer PA, McMillan C, Antonyshyn OM. A new system for severity scoring of facial fractures: development and validation. J Craniofac Surg. 2010 Jul. 21(4):1098-103. [Medline].

  5. Caron G, Paquin R, Lessard MR, et al. Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma. 2000 Feb. 48(2):235-40. [Medline].

  6. Stoll P, Galli C, Wachter R, Bahr W. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth. 1994 Jan-Feb. 6(1):83-6. [Medline].

  7. Babu I, Sagtani A, Jain N, Bawa SN. Submental tracheal intubation in a case of panfacial trauma. Kathmandu Univ Med J (KUMJ). 2008 Jan-Mar. 6(1):102-4. [Medline].

  8. Shetty PM, Yadav SK, Upadya M. Submental intubation in patients with panfacial fractures: A prospective study. Indian J Anaesth. 2011 May. 55(3):299-304. [Medline]. [Full Text].

  9. Garg M, Rastogi B, Jain M, Chauhan H, Bansal V. Submental intubation in panfacial injuries: our experience. Dent Traumatol. 2010 Feb. 26(1):90-3. [Medline].

  10. Berardo N, Leban SG, Williams FA. A comparison of radiographic treatment methods for evaluation of the orbit. J Oral Maxillofac Surg. 1988 Oct. 46(10):844-9. [Medline].

  11. DeMarino DP, Steiner E, Poster RB, et al. Three-dimensional computed tomography in maxillofacial trauma. Arch Otolaryngol Head Neck Surg. 1986 Feb. 112(2):146-50. [Medline].

  12. Singh M, Ricci JA, Caterson EJ. Use of Intraoperative Computed Tomography for Revisional Procedures in Patients with Complex Maxillofacial Trauma. Plast Reconstr Surg Glob Open. 2015 Jul. 3 (7):e463. [Medline].

  13. Gillespie JE, Quayle AA, Barker G, Isherwood I. Three-dimensional CT reformations in the assessment of congenital and traumatic cranio-facial deformities. Br J Oral Maxillofac Surg. 1987 Apr. 25(2):171-7. [Medline].

  14. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg. 1983 Feb. 41(2):89-98. [Medline].

  15. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg. 1990 Oct. 1(4):168-78. [Medline].

  16. Tang W, Feng F, Long J, et al. Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis. Dent Traumatol. 2009 Apr. 25(2):171-5. [Medline].

  17. Bellamy JL, Mundinger GS, Flores JM, et al. Facial fractures of the upper craniofacial skeleton predict mortality and occult intracranial injury after blunt trauma: an analysis. J Craniofac Surg. 2013 Nov. 24 (6):1922-6. [Medline].

 
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Coronal view of patient with panfacial fractures from facial trauma.
Close-up view of left zygomatic comminution.
Coronal view demonstrating cant of maxilla and mandible.
Axial view demonstrating increased zygomatic width.
Three-dimensional reconstruction aids in treatment planning of these complex panfacial fractures.
Large stellate upper lip laceration demonstrating comminution of anterior maxilla.
Traumatic telecanthus secondary to nasoorbitoethmoid fracture. Intercanthal distance is 39 mm.
Intermaxillary fixation in place. Note comminution of mandible.
Coronal approach used to access mid face.
Comminuted zygomatic arch.
Coronal access to nasal and medial orbital components.
Mandible stabilized with plate-and-screw fixation.
Fixation of zygoma and zygomatic arch.
Fixation of nasoorbitoethmoid component.
Maxillary fixation at the level of the zygomaticomaxillary buttress and the piriform rim.
Postoperative coronal CT scan image.
Postoperative axial CT scan image.
Postoperative view of patient.
Postoperative frontal view of patient, demonstrating good facial symmetry.
Postoperative profile view of patient, demonstrating good nasal dorsal and zygomatic anterior-posterior projection.
Postoperative view of patient, demonstrating normal intercanthal distance (33 mm) after resuspension of the medial canthal ligament and fixation of the nasoorbitoethmoid component.
 
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