Management of Panfacial Fractures 

Updated: Nov 02, 2018
Author: Kris S Moe, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS 

Overview

History of the Procedure

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.[1] 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.

Problem

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.[2, 3] 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.[2]

For information on treatment of more isolated facial fractures, see Medscape Reference articles General Principles of Mandible Fracture and Occlusion, Pediatric Mandible Fractures, Zygomaticomaxillary Complex 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.

Etiology

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%).[4] Motor vehicle collisions and gunshot wounds were found to be significant predictors of panfacial fractures.[4]

Pathophysiology

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.[3, 5] 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:[6, 7, 8, 9, 10] 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.[11]

  • 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.

Presentation

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.

Indications

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.

Contraindications

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 Imaging in Orbital Fractures in Medscape Reference's Radiology journal.

 

Workup

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.[12]

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.[13, 14] They can aid in visualization and treatment planning of the bony injuries.[15] See the image below.

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

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.

 

Treatment

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.[6]

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.[16] 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.[17]

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.

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.[18]

  • 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[19]

  • Nasal obstruction and deformities

  • Cerebrospinal fluid leak

  • 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.[20]

See Pathophysiology for complications related to treatment of individual components.

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.