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Management of Panfacial Fractures Workup

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

Imaging Studies

Order plain films as dictated by the physical examination findings.

Because of the complexity of these injuries, computed tomography (CT) imaging studies yield more accurate information related to the bony architecture and its disruption by injury than plain films.[10]

CT imaging is an integral component of the diagnosis of midfacial fractures. These patients often have a concomitant head injury and require a head CT scan to examine intracranial structures and exclude hemorrhage. Often, if the results are positive for injury, the CT scan needs to be repeated to look for worsening or resolution of an intracranial process.

Axial CT scans through the maxillofacial region can almost always be obtained while performing the initial head CT scan. See the image below.

Axial view demonstrating increased zygomatic width Axial view demonstrating increased zygomatic width.

Coronal CT scans are often difficult to obtain initially in patients who are still intubated and require cervical spine immobilization. Coronal and sagittal reconstructions can usually be obtained from the initial axial CT scans. See the images below.

Coronal view of patient with panfacial fractures f Coronal view of patient with panfacial fractures from facial trauma.
Coronal view demonstrating cant of maxilla and man Coronal view demonstrating cant of maxilla and mandible.

Three-dimensional CT imaging and computer-generated models of the facial skeleton can be useful in complex cases.[11, 12] They can aid in visualization and treatment planning of the bony injuries.[13] See the image below.

Three-dimensional reconstruction aids in treatment Three-dimensional reconstruction aids in treatment planning of these complex panfacial fractures.
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Diagnostic Procedures

One of the keys to repair or reconstruction of the maxillofacial skeleton is occlusion of the teeth. Dental models can be helpful in assessing the exact position of displaced segments of both the maxilla and mandible attached to teeth. Dental models are useful in the reconstruction of acrylic stents and splints for palatal fractures.

Preinjury photographs of the patient obtained from the family can be helpful in determining the patient's preinjury appearance and the presence of any preexisting maxillofacial problems such as congenital telecanthus, hypertelorism, apertognathia, prognathism, retrognathism, and nasal deviation.

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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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