The panfacial injury Conceptually, panfacial fractures are
defined as those involving the upper,middle and lower third of
In practice, when two out of these three areas are involved,
the term “panfacial fracture” has been applied.These complex
facial injuries are generally result of high velocity trauma and
often produce complex fractures that are extensive and not in
the patterns as cleanly outlined by Le Fort.
What is it if someone says that you have a Pan face??
The face which is flattened due to an extreme blow by a pan
Racist used to describe it as one of a Chinese decent
Treatment of facial trauma, damage to the dentition and anatomic structures
subsequent to maxillofacial injury is an issue of paramount importance in traumatology.
Because in this field, unlike other parts of the body, not only does the surgeon have to
deal with the management of the facial fractures, but must also restore the facial
functions and features such as visual function (i.e. diplopia), olfaction, breathing (i.e.
airway management), mastication (i.e. restoration of teeth and occlusion), deglutition
and articulation (in addition to the facial appearance of the patient and symmetry).
In no other part of the body is the management of trauma so complex.
Why the management of this type of trauma is so complex?
Pan facial fractures concurrently involve the following bones :
• Naso-orbitoethmoid region,
•Maxilla and mandible.
Incidence And Etiology
Goals & Sequence Of Treatment
Bone Grafting And Soft Tissues Resuspension
Motor vehicle collisions
Sports related accidents
Kapoor P, Kalra N. A retrospective analysis of maxillofacial injuries
in patients reporting to a tertiary care hospital in East Delhi. Int J
Crit Illn Inj Sci 2012;2:6-10
Raval CB, M. Airway management in patients with
maxillofacial trauma - A retrospective study of 177 cases.
Saudi J Anaesth 2011;5:9-14
INCIDENCE & ETIOLOGY
Fossilized cranium and finite element model of
Australopithecus africanus. Bright colors indicate
Buttress:A means or device that keeps
something erect, stable, or secure
The buttress system of face is formed by strong frontal, maxillary, zygomatic ,sphenoid
and mandible bones and their attachments to one another. The central midface
contains many fragile bones that could easily crumble when subjected to strong
forces. These fragile bones are surrounded by thicker bones of the facial buttress
system lending them some strength and stability. These buttress represent the best
available understanding of the mechanical support of face as they determine how an
impact is distributed over the face
For better understanding the components of the facial buttress
system have been divided into:
1. Vertical buttresses
2. Horizontal buttresses
Vertical buttress: These buttresses are very well
developed. Described by manson et al.vertical buttress are
responsible for three dimentional projection of midface .
4. Vertical mandible
Majority of the forces absorbed by midface are masticatory in
nature (vertically oriented). Hence the vertical buttresses are
well developed in humans .
Horizontal buttresses:These buttresses interconnect and provide
support for the vertical buttresses. They include:
a. Frontal bar
b. Infraorbital rim & nasal bones
c. Hard palate & maxillary alveolus
The buttresses represent areas of relative increased bone thickness that
support the functional units of the face (muscles, eyes, dental
occlusion, airway) in an optimal relation and define the form of the face by
projecting the overlying soft-tissue envelope.
Facial buttress pearls are as follows:
(a) The buttress concept was intended for improved appreciation of facial structure; it
does not replace traditional anatomic terms.
(b) Buttresses have sufficient bone thickness to accommodate metal screw fixation.
(c) Buttresses are all linked either directly or through another buttress to the cranium or
cranial base as a stable reference point.
(d) Transverse buttress reduction restores facial profile and width; vertical buttress
reduction restores facial height.
(e) Buttress reduction establishes a functional support for the teeth and globes.
So restoration of 3-D shape of face after panfacial fracture requires precise reduction of
these buttress against stable cranial base or mandible
Source : Diagnosis of Midface Fractures with CT: What the Surgeon Needs to Know.Richard A. Hopper. RadioGraphics 2006; 26:783–793
When there is panfacial fractures
,reconstruction should be approached as a
puzzle. Known landmarks can be used to
reconstruct more precisely those areas that
have been damaged. These landmarks may help
in establishing the proper positioning of facial
1. Dental arches
2. The Mandible
3. Sphenozygomatic suture
4. Intercanthal region
• When one or both dental arches are intact they can be used to a guide to establish proper
• Clinical scenario of Midpalatal split + fracture of the tooth bearing region of the mandible +
condylar fracture. 3 options:
1. Establish maxillary width by exposing the palatal fracture and doing reduction and rigid
2. Take impressions for fabrication of dental models . Perform simulated surgery on upper and
lower arches and fabricate a surgical splint.
If the patient has dental models from preinjury orthodontic or prosthodontic
rehabilitation, these can provide good clues to establishing proper arch form.
3. Reconstruct the mandible first as it is a very robust bone that can be anatomically reduced if
attention is paid to detail.
• Aim to achieve anatomical reduction of both lingual and buccal cortical surfaces
prior to fixation.
• Bilateral subcondylar fractures must be treated to establish posterior facial height
and facial width.
• Bilateral subcondylar fracture + fracture of the symphysis and or body- the
mandible may undergo splaying (widening).The condyle can be reconstituted to
ramus to help establish facial height and width.
• Situated along the internal surface of the lateral orbital wall.
• Is a key landmark for reduction and fixation of the zygomaticomaxillary complex
provided the orbital roof and lateral orbit are intact .
• Likewise the zygomatic buttress is important in establishing the proper position of
the zygoma and or maxilla.
• If there is gross bone loss in this are, primary bone grafting may be indicated to
reestablish the buttress.
The surgeon should pay particular attention to the alignment of the zygoma
and sphenoid at the lateral orbital wall, since angulation here after fixation of the remaining
buttresses reflects a residual rotational deformity and an associated increased orbital volume.
• Intercanthal distance if fairly constant in adult facial skeleton.
• May be used to reestablish midfacial width if the naso-orbitoethmoid complex is
not severely comminuted.
• Direct measurement in cases of severe comminution can help in establishing the
proper facial width
Before the advent of CT scanning, plain film radiography and
linear tomography were the gold standard for imaging of facial
Initially, 5mm cuts through facial skeleton could be made;
now 0.75mmaxial cuts with coronal reconstructions is possible
(allows 3-D reconstructions if needed and decreases the
number of repeat scans)
High resolution CT scanning allows the surgeon to
i. evaluate details of the fracture pattern
ii. View hard and soft tissue details-intracranial injuries; injuries
to the globe; foreign bodies; extra-ocular muscle entrapment;
soft tissue avulsion; displaced teeth and the airway.
iii. Simultaneous imaging of cervical spine if injury is suspected.
Iv. Allows better treatment planning/sequencing
If the rectus remains flattened in cross-
section and in the correct position, the
fascial sling is likely intact and the surgeon
will encounter minimal entrapped
periorbital tissue (Fig 10a). However, if
the inferior rectus is round and inferiorly
displaced, the fascial sling is disrupted and
the periorbita and muscle have prolapsed
into the orbital floor defect
(a) normal anatomy of the orbital apices
(b) impingement of the orbital apex secondary to
a sphenoid–skull base fracture.
An isolated blow-in fracture of the left orbital roof
.The associated exophthalmos and dural tears were
treated with an intracranial approach.
Orbital fracture pearls are as follows:
(a) Orbital fractures can occur in isolation or with other fracture patterns.
(b) The position and shape of the medial and inferior rectus muscles can indicate whether entrapment and
clinical diplopia are likely.
(c) Pediatric trapdoor orbital fractures are a surgical emergency.
(d) The size of the orbital floor defect can be underestimated in severely Impacted ZMC fractures.
(e) Medial orbital wall blow-out fractures cause enophthalmos if the posterior- medial orbital bulge is lost.
(f) Orbital apex compression with clinical decreasing vision is a surgical emergency.
Radiologic description of NOE fractures should comment on the
degree of comminution of the medial vertical maxillary buttress,
specifically in the region of the lacrimal fossa, where the medial
NOE fracture pearls are as follows:
(a) NOE fractures are distinguished from simple nasal fractures by posterior disruption of the medial canthal
region, the ethmoids, and the medial orbital walls.
(b) Clinically, the most obvious deformity is loss of nasal projection in profile and apparent increased distance between
the inner corners of the eyes.
(c) NOE fractures can be classified by the degree of injury to the region where the medial canthus attaches around the
(d) Although the frontal sinus may not be directly injured, if the nasofrontal ducts are disrupted, then frontal sinus
surgery is needed to prevent a mucocele in the future.
a displaced fracture of the left zygoma.
The rotational deformity of the zygoma is
demonstrated by angulation of the lateral
orbital wall at the zygomaticosphenoid suture.
The lateral displacement (black arrow) of the
lateral vertical buttress (*) has resulted in
increased orbital volume and enophthalmos
As long as the rotational deformity is
corrected and the other maxillary
buttresses are fixated by means of limited
incisions, the zygomatic arch does not
need to be exposed
ZMC fracture pearls are as follows:
(a) The ZMC relates to the temporal bone, maxilla, frontal bone, and skull base and is therefore a quadripod
(b) Displaced ZMC fractures often increase orbital volume by angulation of the lateral orbital wall at the
zygomaticosphenoid suture or blow-out of the orbital floor.
(c) The zygomatic arch establishes both facial width and profile. Surgical exposure is indicated if it is severely
comminuted or angulated.
Bilateral Le Fort I, II, and III fractures. The lateral and
medial maxillary buttresses (white lines) are fractured
inferiorly and superiorly (junctions of white lines and
To confirm the diagnosis, pterygomaxillary
disjunction and fractures of the zygomatic arches
would need to be observed on axial images.
A right-sided unilateral pterygomaxillary disjunction, which
has resulted in separation of the posterior vertical maxillary
buttress (*) from the rest of the maxilla; this appearance is
indicative of a Le Fort fracture.
The contralateral pterygomaxillary junction is intact because
the fracture exited in the form of a parasagittal palate
Le Fort fracture pearls are as follows:
(a) All Le Fort fractures require disruption of the pterygoids from the posterior maxilla, as seen at
(b) Any combination of Le Fort I, II, and III patterns can occur.
(c) A sagittal or parasagittal hard palate fracture with a Le Fort pattern will result in a widened
(d) Displaced unilateral Le Fort fractures are possible only with a sagittal or parasagittal palate
Fracture repair should be initiated as soon as the patient's other injuries permit.
Particularly in midfacial fracture repair Paul Manson’s quote: “you never get a second
chance” has to be kept in mind .Early management of fractures facilitates reduction and
avoids the insult of a second injury to soft tissues in a vulnerable period of early wound
healing. Reduction and fixation of complex injuries within 48 hours is ideal; management
within 10 days is critical because soft-tissue stiffening and interfragmentary healing make
later corrections very difficult.
It is not so much the fracture morphology in the midfacial area that limits the intended
treatment but mainly the preexisting general health status and the severity of associated
accompanying injuries or in the vicinity of the midface (optic nerve trauma, CSF leakage,
bleeding, etc) or in independent locations.
Designed to achieve wide exposure of the
fracture lines which is essential for accurate
The location and extent of exposure are
dependent upon fracture severity and
•Superior part of naso-orbito ethmoid
•Medial canthal tendon
•Superior aspect of lateral orbital wall
•Mandibular condyle (with
Subciliary and transconjuctival incision with
•lateral orbital wall
•Orbital floor & frontozygomatic suture:
transconjuctival incision with lateral canthotomy .It
requires detachment of lateral canthal ligament and
incision through orbicularis oculi muscle and
periosteum deep to lateral periorbital skin.
•The subciliary approach :lateral nasal region.
Upper eyelid crease incision
•Superior and lateral orbital region
•Not required when the bicoronal flap is used
•Medial canthal tendon
•Disadvantage: significant scarring occurs
•Not required if Bicoronal flap is used
Maxillary vestibular incisions
Mandibular vestibular incision
•Mandible from ramus to symphysis
•Not recommended for comminuted fractures
•Mandible except for high condylar neck
•Indicated when anatomic reduction is
•Comminuted mandibular fractures and
fracture of edentulous and atrophic mandible
•Allows the surgeon to visualize the reduction
of the lingual cortex.
The 3 goals of therapy in treating panfacial fractures are
To restore functional occlusion
To stabilize the major facial skeletal supports, thereby restoring the premorbid 3-dimensional
contour (height, width, and projection) to the face; and
Proper restoration of the bony facial scaffold to provides a stable support upon which the
overlying soft tissue matrix may heal.
Facial Fracture Classification According to Skeletal Support Mechanisms
Terry L. Donat, Carmen Endress, Robert H. Mathog, .Arch Otolaryngol Head Neck Surg. 1998;124(12):1306-1314
Unsatisfactory results in pan facial # treatment:
Lack of exposure
Inadequate reduction or fixation of soft tissue or bone and
Insufficient primary bone grafting
Dictated by fracture pattern, extent of other injuries
Extensive head injuries and prolonged intubation anticipated-
tracheostomy(it also facilitates management of multiple facial #.
Extensive injuries in NOE Region make nasal intubation difficult
If IMF is not possible or not indicated- oral intubation /submental
/retromolar (in c/o symphysis/body #submental intubation hinders
Sequence Of Repair
Manson says that when multiple areas of face are fractured ,an order of treatment
needs to be developed.
The exact order of treatment is not as important as the development of the plan that
permits both flexibily and reproducibly accurate positioning of the various fracture
Different orders of treatment have been proposed ,any of which are satisfactory if
one understands the anatomy ,goals, and procedures.
This issue however relate more to the experience and habits of surgeon and
prevention of common treatment errors.
Much has been written about proper sequencing of treatment for Panfacial
fractures. “Bottom up & inside out” or “Top down & outside in” have been used to
describe 2 of classic approaches for management of Panfacial fractures
Traditionally, complex reconstruction began with the reestablishment of
occlusion and repair of mandibular fractures. From this foundation, the
upper face was reconstructed.
Another strategy supported by craniofacial surgeons began
reconstruction with the external frame of the face, including the frontal
bar, zygomatic arches, and orbital rims .This approach emphasized the
importance of the zygomatic arch in the control of facial width and its
reciprocal, facial projection.
One strategy focuses on repair of the central upper midface after
occlusion has been reestablished . This technique, although
emphasizing the importance of controlling facial width, recognizes that
, the NOE , is the most difficult region to narrow acutely. Minor
deformities in this aesthetic core, which is one of the primary focuses of
visual attention in human interaction, are easily noticeable and
extremely difficult to repair secondarily.
Addressing lateral midface first risks compounding small unavoidable
imperfections in reduction, thus compromising the central core. With
this in mind, the lateral zones including the zygomatic arches and orbital
rims are repaired after frontal and naso-orbital-ethmoid repair has
How these approaches came in use with time?
SEQUENCING AND ORGANIZATION OF THE REPAIR OF PANFACIAL FRACTURES.MICHAEL A. FRITZ, MD, PETER J. KOLTAI, MD
.OPERATIVETECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 13, NO 4 (DEC), 2002: PP 261-264
It is important to recognize the
contributions of each facial component to
critical dimensions of facial width,
projection and height.
Key contributors to central facial width
are the naso-orbital-ethmoid complex,
the palate, and the mandibular arch.
Lateral facial width :The frontal bar,
zygomatic arches, malar eminences, and
Projection, the reciprocal of width,
:frontal bar, frontonasomaxillary
buttresses, zygomatic arches, and
mandible from angle to symphysis.
Facial height: The frontal bone, midface
buttresses, and mandibular angles and
SEQUENCING AND ORGANIZATION OF THE REPAIR OF PANFACIAL FRACTURES.MICHAEL A. FRITZ, MD, PETER J. KOLTAI, MD
.OPERATIVETECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 13, NO 4 (DEC), 2002: PP 261-264
An exploded view of a child's
facial skeleton highlighting
component units. For severe
component units are first
Units are then connected to each
other and to the cranium via their
Review of facial subunits
The face is divided into upper and lower half at
lefort –I level.
Each facial half is divided into two facial units:
occlusal unit-teeth,palate,dentition ,alveoler
process of maxilla and mandible
mandibular units-1.horizontal(basal mandible)-
Cranial unit-frontal ,ant. Temporal bones ,
supraorbital rims, orbital roofs, frontal sinus.
Upper midface-zygoma laterally, nasoethmoid
area centrally ans medially, lat. & inferior portion of
the orbits bilaterally.
occlusion : (1,2,3)
•#of the hard palate are repaired first(rigid) to set the width of the lower central
•If palatal # and comminuted mandibular # coexist, occlusal relationships are very
difficult to ascertain, Reducing and rigidly fixing hard palate # on both inside and
A-S in the nasal spine and pyriform region can provide stable guide for mandibular
•Severely comminuted # of palate and horizontal mandible necessitates the
manufacture of a splint .(key)
•After occlusion has been restored, attention can be directed to either the central
upper or lower face depending on concomitant neurosurgical Intervention.
Lower face: (4,5/11,12)
•Central fractures are exposed, reduced, and rigidly fixed.
•Check occlusion always
•Attention is then directed to the lateral mandible.
•Comminuted mandibular fractures are repaired through reassembly
of small fragments into larger segments and subsequent linkage and bone
grafting when necessary under a sturdy reconstruction plate scaffold.
•Loss of vertical mandibular height, significant fracture displacement, and co-
existing mobile LeFort fractures require open reduction and fixation of ramus
fractures, subcondylar fractures, and cond¥lar dislocations (particularly when
they are bilateral).
This importantly reestablishes the appropriate length & relationship
With cranial base
Cranial unit (6)
• Frontal bone fractures are reduced
•Frontal sinuses are obliterated or cranialized when mandated by presense or absense of the posterior
frontal sinus wall, respectively.
•Isolate nose from cranial cavity by by cranial base grafting
•The frontal bar is then reconstructed by stabilizing lower ant. Sinus with S-O rim.-stable
landmark.(temporal bone alingment must be correct to assure proper projection of frontal bar.
•Orbital roof reconst. With grafts.(avoid over grafting)
A, Clinical photograph of patient
who has a naso-orbitoethmoid
fracture with an
intercanthal distance of 43 mm.
photograph showing exposure
of the nasoorbitoethmoid
•Upper mid face unit:
•Accurate repositioning of the zygomatic complex ensures
•the restoration of lateral facial width and projection.
•The zygomatic arches are reconstructed and reunited to the
temporal bone posteriorly.
•Key to proper reduction is alignment of orbital portion of
the zygoma and the greater wing of the sphenoid at the
lateral orbital wall.“
• The inferior orbital rim is then stabilized.
•The last area of the lateral midface to be addressed is the Z-
F suture because this relationship contains the strongest
bone and is the poorest guide to proper reduction.
Linking upper and lower face:
•The upper and lower midface are linked at the
LeFort I level through fixation of the four anterior maxillary
•Midfacial height is determined using an intact or reconstructed
maxillary buttress as a guide.
• Liptooth position may provide information about facial
height if extensive comminution or bone loss is present.“
•Buttress gaps exceeding 5 mm should be bone-grafted.
•After this has been accomplished, the orbital floors are
addressed with reduction, fixation, and bone grafting as
•The nasal dorsum is then reconstructed with a
cantilever cranial bone or rib graft with columellar strut
grafting and reattachment of the septum to the nasal spine
Facial width is the most important component of facial dimentions .In treated #,facial height ↓,projection ↓,but
width ↑ ,as a result face looses its elongated, sophisticated look and becomes more spherical.
Control o f Width allows projection to be reciprocally established.
Malar eminence projection is assessed by inspecting Sphenozygomatic suture.
Pterygoid buttress are not addressed in any current facial repair scheme. Its stab. Is achieved indirectly by
relating u/l alveoli by IMF
In severe hypertelorism ,it may not be possible to reduce palate until upper face is reduced. Muscular origins
must be reduced before their insertions can be narrowed.
In edentulous max. #, proper projection is only confirmed by relating U/L ridges by splints/dentures as buttress
are guide for max . height not projection.
The fracture pattern occurring in symphysis/parasymphysis region associated with fracture of condyle(s) result in
retrodisplacement of mandible with widening at angles. Under such conditions all fractures should be exposed
prior to reduction and fixation of anyone of them. Pressure should be applied at gonial angles to close any lingual
gap to establish lower facial width and achieve correct anterior projection.
Some important points
BOTTOM UP ,INSIDE OUT
•Repair of palatal fracture
•Repair of mandibular #
•Repair of condyle #
•Repair of frontal sinus #
•Repair of NOE complex
•Repair of ZMC # including arches
•Repair of maxilla
•Repair of frontal sinus fracture
•Repair of ZMC(bileteral) # including arches
•Repair of NOE complex
•Repair of le fort including mid palatal split
•Repair of bicondyle #
•Repair of mandibular #
Re-establish the maxillo-mandibular unit as
the first major step of the sequencing
Starting with the reduction and fixation at the level
of the calvarium and working in a caudal direction
Top- down ,outside in
Open treatment of condyle may not be necessary. The patient is treated with varying period of
IMF ,which may be valid approach in c/o comminuted intracapsular #
1.unrecognized rotation of body or ramus of mandible ,resulting in widening.
2.TMJ ankylosis caused by inability to begin early physical therapy-compromised result.
With high-velocity trauma, comminution and loss of bony segments can occur in the
buttress and “nonbuttress” areas of the face.
When these defects are significant, the surgeon may consider the use of bone
grafting to prevent soft tissue collapse and to allow for structural support of the facial
Common areas that may require primary bone grafting include the frontal bone, nasal
dorsum, orbital floor, medial orbital wall, and zygomaticomaxillary buttress.
There are many potential sources of bone for a graft, but calvarial bone may be the
Access is often achieved through a Bicoronal flap that has already been created
during the management of the fractures.
Rigid fixation of these grafts has been shown to decrease resorption.
Bone Grafting and
Soft Tissue Resuspension
Two procedures have improved outcomes in the management of panfacial
Primary bone grafting
Resuspension of the soft tissue after extensive exposure of the facial
Primary bone graft rigidly
fixed into position to reconstruct the
anterior maxillary sinus wall
including the nasomaxillary
and zygomaticomaxillary buttress
Soft tissue resuspension after surgical access to facial fractures is
important for long-term facial esthetics.
For repair of PANFACIAL face fractures, usually large exposure of
# sites is required.
The soft tissue attachment over the midface is almost
This frequently results in sagging of the soft tissue, with
reattachment at a more inferior position.
Manson stated two steps to placing the soft tissue back into
proper position after exposure :
Refixation of the periosteum or fascia to the skeleton,
Closure of the periosteum, muscle fascia, and skin where
incisions have been made.
The periosteum is inflexible and limits soft tissue lengthening
and migration. Its reattachment is usually accomplished by drilling
holes in key locations to fix the periosteum to the bone.
Areas where periosteal reattachment should be obtained include
- malar eminence and infraorbital rim, temporal fascia over the
zygomatic arch, medial and lateral canthi, and mentalis musc
Areas where periosteal closure should be obtained include - f-z
suture, infraorbital rim, deep temporal fascia, and muscular layers
of maxillary and mandibular incisions.
Soft tissue resuspension
Reconstruction of pan facial injuries is simplified by a highly organized treatment sequence
that conceptualizes the face in two groups of two subunits.
Each unit is divided into sections and each section is assembled in three dimentions.
Sections are integrated into units and units into a single reconstruction.
Conceptually ,in each unit.facial width must first be controlled by orientation from cranial
base landmarks .Projection is then established.
Finally ,facial length is set both in individual units and in the upper and lower face.
Soft tissue is considered as the “fourth dimention” of facial reconstruction.
Bone reconstruction shd be completed as early as possible to minimize soft tissues in non
anatomic positions . S/T that heals from a single insult over anatomically constructed bone
support provides the most natural facial appearance.
Neither one of these techniques will achieve optimal results in
Instead, an approach that goes from known to unknown is
certainly more accurate.
For e.g. if there is significant calvarial injury , it may be
difficult to start from cranium and proceed caudally. In this
case ,a sequence that starts caudally and proceeds cranially
may achieve more optimal results, allowing the surgeon to
reconstruct the damaged cranial portion last.
Conversely, if there communication of mandible ,it maybe
more appropriate to start cranially and proceed caudally.
Thus a maxillofacial trauma surgeon must be comfortable
with both approaches and use known landmarks to achieve
Incisions frequently used for orbital surgery. Deep approaches:
A, Stallard-Wright lateral orbitotomy incision; B, lid crease with
lateral extension; C, modified Berke lateral canthotomy
incision; D, transcaruncular incision; E, frontoethmoidal “Lynch”
incision. Anterior approaches: F, upper lid crease incision, G,
vertical lid split incision; H, transconjunctival medial
orbitotomy; I, lateral canthotomy incision; J, lower lid
percutaneous incision; K, transconjunctival lower lid incision.