Management of Panfacial Fractures Workup

  • Author: Kris S Moe, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS   more...
 
Updated: Feb 2, 2012
 

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 widthAxial 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 fCoronal view of patient with panfacial fractures from facial trauma. Coronal view demonstrating cant of maxilla and manCoronal 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] They can aid in visualization and treatment planning of the bony injuries.[12] See the image below.

Three-dimensional reconstruction aids in treatmentThree-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 Academy of Otolaryngology-Head and Neck Surgery, American Society for Head and Neck Surgery, and North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

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, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine 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. Feb 1991;24(1):93-101. [Medline].

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

  3. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. Apr 2008;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. Jul 2010;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. Feb 2000;48(2):235-40. [Medline].

  6. Stoll P, Galli C, Wachter R, Bahr W. Submandibular endotracheal intubation in panfacial fractures. J Clin Anesth. Jan-Feb 1994;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). Jan-Mar 2008;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. May 2011;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. Feb 2010;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. Oct 1988;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. Feb 1986;112(2):146-50. [Medline].

  12. 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. Apr 1987;25(2):171-7. [Medline].

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

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

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

  16. Irby WB. Facial Trauma and Concomitant Problems: Evaluation and Treatment. 2nd ed. St. Louis, Mo: CV Mosby; 1979.

  17. Tullio A, Sesenna E. Role of surgical reduction of condylar fractures in the management of panfacial fractures. Br J Oral Maxillofac Surg. Oct 2000;38(5):472-6. [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.
Initial clinical presentation of a patient with panfacial fracture.
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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