how to manage panfacial fracture

1. PANFACIAL FRACTURES
JAMEEL KIFAYATULLAH

2. PANFACIAL FRACTURES
• involve fractures of each of the upper, middle,
and lower thirds of the face
• complex fractures that can result in collapse
of facial dimensions as well as malocclusion
• concomitant ocular, cerebral, and c-spine
injuries, as well as multisystemic trauma
throughout the body

3. Main goals in panfacial trauma
The main goals in panfacial trauma
to reestablish the anteroposterior projection,
facial height, width, and symmetry along with
a functional occlusion.

4. Goals in panfacial truama
• The horizontal and vertical buttresses of the
facial skeleton are key areas of focus in
accomplishing this.
• In addition, the zygomatic arch is a critical
buttress in anteroposterior projection as well
as prominence of the cheeks.

5. Approaches
Several approaches have been used for the
treatment of panfacial trauma:
top-to-bottom
bottom-to-top
the outside-in

7. Surgical technique (panfacial)
• Preoperative planning:
Preoperative CT imaging
intraoperative CT scanning and navigation
• Prep and patient positioning
supine position on the operation table
the upper and middle face is kept exposed
submental intubation technique
tracheostomy

8. Surgical approach and procedure
INCISIONS:
• coronal access to upper and midface fractures
and the zygomatic arches
• periorbital incisions where indicated
• both intraoral and extraoral approaches to the
maxilla and mandible.

9. Bottom to top Approach
• The mandible is addressed first
use of occlusal splints to restore the occlusion
• if there are any condylar fractures, they must be
reduced first to restore the lower posterior facial
height and width
• ORIF of the fractures may be indicated
• Following fixation of the mandible, the maxilla is
placed into occlusion with the mandible and
maxillomandibular fixation is applied to create a
maxillomandibular unit.

10. Bottom to top Approach
• This complex can then be fixated to the rest
of the skull base to the correct vertical
dimension
• . The zygomaticomaxillary buttress is often the
best and most reliable site for fixation. Once
the maxillomandibular unit is reduced and
fixated, the middle and upper facial thirds will
follow.

11. Top to bottom/outside in
• Advocated by Gruss and Phillips
• the establishment of the outer facial frame first
and then basing the remaining fixation off this
stable frame
• mainly focuses on the reduction and projection of
the zygomas, including the zygomatic arches as
well as the frontal bar
• The surgeon then works inward, reconstructing
the NOE complex and eventually the orbits if
indicated.
• From this point the maxilla and mandible can be
fixated to this reestablished facial frame.

13. Immediate postoperative care
• medical management of the patients and their
medical comorbidities , monitoring for
bleeding, and checking laboratory values if
significant blood loss was encountered during
the operation
• Persistent CSF leak, neurologic decline, and
signs or symptoms of infection are important
points of inspection postoperatively
• monitor the patient’s eyes and vision if orbits
involved

14. Immediate postoperative care
• Ophthalmologic complications, such as
enophthalmos and ectropion, as well as
traumatic telecanthus, saddle nose defect,
and scarring, are important considerations
• Inspection of soft tissues

15. Rehabilitation and recovery
• Functional occlusion must be reestablished in all
facial fractures and aggressive rehabilitation of
mouth opening early on is recommended.
• Patients with intracranial injuries may also
require long-term rehabilitation at specialized
facilities
• Patients with frontal sinus fracture also require
long-term follow-up indefinitely to monitor for
signs of mucocele/ mucopyocele, brain abscess,
and osteomyelitis

16. Rehabilitation and recovery
• A CT scan should be taken every 5 years after
the first year of follow-up and endoscopic
techniques may also be used for postoperative
monitoring
• control of soft tissue scarring:big problem
• Application of a larger nasal splint and/or use
of lead plates may assist in soft tissue
adaptation to the underlying bones