You are in: eMedicine Specialties > Plastic Surgery > FACIAL FRACTURES Facial Trauma, Management of Panfacial FracturesArticle Last Updated: Mar 10, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Adel R Tawfilis, DDS, Assistant Clinical Professor, Department of Surgery, Division of Plastic Surgery, University of California at San Diego Medical Center Adel R Tawfilis is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, and American Society of Maxillofacial Surgeons Coauthor(s): Patrick Byrne, MD, Assistant Professor, Department of Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Johns Hopkins University; Louie Limchayseng, DMD, FACD, Associate Professor of Oral and Maxillo-Facial Surgery, Department of Surgery, Division of Oral and Maxillofacial Surgery, Alameda County Medical Center and Highland General Hospital; David W Kim, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Director, Division of Facial Plastic and Reconstructive Surgery, University of California at San Francisco Editors: James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: plate and screw fixation, plate-and-screw fixation, rigid fixation, midface injury, mid-face injury, midface reconstruction, mid-face reconstruction, panfacial injury, complex maxillofacial injury, panfacial trauma, facial fracture, face fracture, maxillofacial surgery, maxillofacial reconstruction, maxillofacial repair, maxillofacial injury, maxillomandibular fixation, MMF, panfacial fracture, facial trauma INTRODUCTIONSection 2 of 10
  History of the ProcedureThe 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. ProblemPanfacial injuries involve trauma to the upper, middle, and lower facial bones. Multisystem injury or polytrauma is commonly associated with these injuries; thus, treatment often requires a team approach. After stabilization of the patient, early and total restoration of facial form and function should be the goal of the maxillofacial surgeon. PathophysiologyIn 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. 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:
ClinicalThe 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. INDICATIONSSection 3 of 10
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. CONTRAINDICATIONSSection 4 of 10
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. WORKUPSection 5 of 10
Imaging Studies
Diagnostic Procedures
TREATMENTSection 6 of 10
Preoperative detailsPreoperative 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. 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. Intraoperative detailsThe 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. 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 determine access to the facial skeleton by using the appropriate incisions for the specific bony injuries. Access to the mid face can be obtained through a variety of incisions; however, a subciliary or transconjunctival incision, a lateral brow or upper blepharoplasty incision, and an intraoral vestibular incision coupled with a coronal incision provide access to the entire mid face. 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. 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). Second, reconstruct the inner facial frame (ie, nasoethmoid complex, zygomaticofrontal sutures, infraorbital rim). Third, reconstruct the maxilla at the Le Fort I level by plating the buttresses. 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. COMPLICATIONSSection 7 of 10
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 naso-orbito-ethmoidal fractures. Complications associated with complex maxillofacial injuries include the following:
See Pathophysiology for complications related to treatment of individual components. OUTCOME AND PROGNOSISSection 8 of 10
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. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Facial Fracture. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Facial Trauma, Management of Panfacial Fractures excerpt Article Last Updated: Mar 10, 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
