Why should we start from mamndibula fracture in pff

1. PRESENTED BY –
DR. SHEETAL KAPSE
1st YEAR, P.G. STUDENT
MODERATORS -
DR. SUNIL VYAS
DR. M. SATISH
DR. MANISH PANDIT
DR. DEEPAK THAKUR

2. WHY SHOULD WE START FROM
MANDIBULAR FRACTURES IN THE
TREATMENT OF PANFACIAL
FRACTURES?
Yang R, Zhang C, Liu Y, Li Z, Li Z :Why should we start from mandibular
fractures in the treatment of panfacial fractures? J Oral Maxillofac
Surg. 2012 Jun;70(6):1386-92. doi: 10.1016/j.joms.2011.11.006.

3. Authors
1. Rongtao Yang - PhD, DDS
Doctor, State Key Laboratory Breeding Base of Basic Science of Stomatology
(Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education,
School and Hospital of Stomatology, Wuhan University, China
2. Chi Zhang - PhD, DDS
Attending Doctor, State Key Laboratory Breeding Base of Basic Science of
Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of
Education, School and Hospital of Stomatology, Wuhan University, China
3. Yong Liu - MDS, DDS
Doctor, State Key Laboratory Breeding Base of Basic Science of Stomatology
(Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education,
School and Hospital of Stomatology, Wuhan University, China
4. Zhi Li, PhD, DDS
Associate Professor, Department of Oral and Maxillofacial Surgery, School and
Hospital of Stomatology, Wuhan University, China
5. Zubing Li - PhD, DDS
Professor, Department of Oral and Maxillofacial Surgery, School and Hospital of
Stomatology, Wuhan University, China

4. Source of data
 State Key Laboratory Breeding Base of Basic Science
of Stomatology (Hubei-MOST) & Key Laboratory of Oral
Biomedicine Ministry of Education, School and Hospital
of Stomatology, Wuhan University, China.

5. Inclusions -
1. Abstract
2. Introduction
3. Objectives
4. Patients & methods
5. Statistical analysis
6. Results
7. Discussion
8. Conclusion
9. Resources

6. Abbreviation used
PFFs = panfacial fractures
NOE = naso-orbito-ethmoid complex
TMJ = temporomandibular joint

7. Abstract
 Clinically, the "bottom-up” and “outside-in" sequence is usually applied
in the management of panfacial fractures (PFFs). However, findings to
prove that a sequence initiated from the mandible is reasonable are not
available.
 The data from 107 patients with PFFs from 1998 to 2008 were analyzed
retrospectively. All cases were treated with the "bottom-up and outside-
in" sequence.
 The most common sites of mandibular fractures in PFFs were the
symphysis and condyle. The most common type of fracture was the
isolated linear fracture.

8.  Significant differences between mandibular fractures in PFFs
and general mandibular fractures were found. The type
distribution in the former was simpler than that in the latter; the
severity was also less serious.
 Most PFF patients treated with the proposed sequence presented
with satisfactory effects.

9. Introduction
 Panfacial fractures (PFFs) are defined as fractures that simultaneously
involve the upper, middle & lower face. This type of trauma mainly
involves the mandible, maxilla, zygomatic complex, naso-orbito-ethmoid
(NOE) region & frontal bone & is often associated with emergencies.
 Clinically the traumatic conditions of PFFs are complicated & vary
between patients. However a well developed clinical planning &
prognostic evaluation has yet to be reached.
 Most commonly used approach is – “bottom-up” & “outside-in”
 Bottom-up : reduction of fracture from mandible to frontal bone
 Outside-in : zygomatic complex, maxilla & NOE region.

10. Andrew C. Smith, Susan E. Barry, Inferior alveolar nerve damage following
removal of mandibular third molar teeth. A prospective study using
panoramic radiography. Australian Dental Journal 1997;42:3.
Wenig BL:Otolaryngologic Clinics of North America [1991, 24(1):93-101]
 This classic approach can't resolve all possible cases of PFFs.
 Inside-out, immobile-mobile & simple- complicated fractures.
 Mandibular fracture in PFFs – 1st step of choice……
Merville L. Multiple dislocations of the facial skeleton J Maxillofac Surg. 1974 Dec;2(4):187-200.
Erol, Behçet, Rezzan Tanrikulu, and Belgin Gorgun. "Maxillofacial Fractures. Analysis of
demographic distribution and treatment in 2901patients (25-year experience)." Journal of Cranio
Maxillo Facial Surgery 32.5 (2004): 308-313.

11. But WHY ???????
The present study was designed to analyze the distribution
features of mandibular fractures in PFFs & provide detail
data to support the initiation of PFFs treatment from the
mandible .

12. OBJECTIVE
 The objective was to describe the distribution of
mandibular fractures in PFFs and investigate the
basis for initially addressing the mandible when
treating PFFs.

13. Patients and methods

14.  The data from 107 patients with PFFs admitted to
the Dept. of Oral & Maxillofacial Surgery , School
& Hospital Of Stomatology, Wuhan University
(China) From January 1998 To December 2008
were retrospectively analyzed .
 The institutional review board of Wuhan
university approved the protocol, survey &
consent forms used.

15. INCLUSION CRITERIA
 Simultaneous fracture of mandible, maxilla & zygomatic complex with or
without fractures in NOE &/or frontal bone.
 Patient with alveolar fracture of maxilla or mandible were excluded.
 Male : female = 8.7:1 (96 male & 11 female)
 Age = 16 – 64 years.
Dongmei He, Yi Zhang, Edward Ellis III:Panfacial Fractures: Analysis of 33
Cases Treated :Journal of Oral and Maxillofacial Surgery, Volume 65, Issue
12, December 2007, Pages 2459-2465
Sawhney CP, Ahuja RB.Faciomaxillary fractures in north India. A
statistical analysis and review of management. Br J Oral Maxillofac
Surg. 1988 Oct;26(5):430-4.

16. Fracture Type
Simple fracture
 Linear fracture or fractures
with minimal or no
displacement.
 Simultaneously simple
fracture of zygomatic
complex, NOE & maxilla
region.
Complex fracture
 Comminuted fractures
 Fractures with displacement
 Bilateral simple fractures
 Complex fracture of one of
the below
- Zygomatic complex,
- NOE
- Maxilla region.

17. Treatments of PFFs
1. Mandibular fracture - open reduction & internal fixation
2. Frontal fracture – coronary incision
3. Zygomatic complex fracture - fixation at sphenozygomatic,
zygomatic arch, zygomaticomaxillry & frontozygomatic suture
4. Maxillary fracture
5. NOE fracture – restoration of intercanthal distance & reattachment
of medial canthal ligament.
6. Skull & orbital fracture - titanium meshes & autologus bone graft
ORIF according to “bottom-up” & “outside-in”

18. Therapeutic Evaluation
On the basis of –
1. Face outline – symmetry without need for
additional surgery for correction
2. Occlusion – in pretrauma level without
need for additional surgery
3. Mouth opening - > 35mm & stable and
normal TMJ function
4. Local deformity - no additional surgery
was necessary for secondary local
deformities in orbital & NOE region, facial
nerve injury & local bony defect.
- Analyzed by 2 similarly trained investigators.
Excellent = 4/4
Good = 3/4
Fair = 2/4
Poor = ¼ or 0/4

19. Statistical analysis
 Data collection and statistical analysis were carried
out with SPSS 16.0 (SPSS Inc., Chicago, IL)
software. (originally, Statistical Package for the
Social Sciences, later modified to read Statistical
Product and Service Solutions)

20. • Total 164 mandibular fractures in 107 patients
• 67/107 (62.6 %) = only 1 fracture in mandible
• 26/107 (24.3 %) = 2 fractures in mandible
• 12/107 (11.2%) = 3 fractures in mandible
• 1/107 (0.9 %) = 4 fractures in mandible
• 1/107 (0.9 %) = 5 fractures in mandible
RESULTS

21. • 148/164 (90.2%) = simple fractures
• 16/ 164 (9.8 %) = comminuted fractures
8 in condyle
4 in body
2 in symphysis
2 in ramus

22. DISTRIBUTION OF TYPE OF MANDIBULAR
FRACTURES IN PFFs

23.  51 Condylar fractures
13 – intracapsular (5/13 comminuted fractures)
28 – condylar neck
10 – subcondylar (3/13 comminuted fractures)

24. Relationship between mandibular fractures &
midfacial fractures or frontal fractures in PFFs
No correlation in
incidence between
mandibular fracture &
frontal fractures in PPF’s
was observed.
p > .05

25. Treatment Effect
 Follow up duration = 3-24 months
 one half of the patients showed certain deficiencies –
18 patients with face outline
7 in occlusion
28 in mouth opening ( 16 – 34 mm)
23 in local deformity

26. DISCUSSION

27.  Site & type of distribution of the mandibular
fractures in PFFs
 The relationship between mandibular fractures & the
prognosis of PFFs
 Compared with representative data of general
mandibular fractures in different sample sizes

28. Site Of Distribution Of The Mandibular Fractures In
PFFs

29. Compared with representative data of general
mandibular fractures in different sample sizes

30.  PPFs – high energy attacks to the front of the face
 Condylar neck fracture is most common in condylar fracture associate
with PPFs
 Subcondylar fracture – in general condylar fracture.

31. Type Of Distribution Of The Mandibular Fractures In
PFFs
Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast Surg 16:105, 1989

32.  The mandible as an isolated bone in the facial region , determines the height of
the lower third of the face by the ramus region & the width & proportion by the
body region.
 The mandible interacts with the maxilla by occlusion & with the skull by
temporomandibular joint, which insures the continuity of both the lower third
of the face & the whole facial skeleton.
 Because of the importance of mandible, the overall treatment difficulties in the
midfacial fractures & the basic treatment principles of fractures , the treatment
of PPFs must be initiated from mandible.
Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast Surg 16:105, 1989
Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the
management of panfacial fractures." British Journal of Oral and Maxillofacial
Surgery 38.5 (2000): 472-476.

33. Any deficiencies in a step would undoubtedly affect the
next step in the treatment sequence for PFFs as such the
mandible is of great significance in the treatment of PFFs
& should be carefully restored.
In case of unusual type of mandibular fractures in PFFs,
extra attention should be exerted.

34.  As a part of TMJ, the condyle affects the mouth opening &
the other functions of TMJ, and maintains the posterior facial
height & sagittal mandibular position. Thus treatment of
condyle benefits the restoration of the mandibular width &
midface projection.
 When Condylar fractures occur ORIF of Condylar fractures
should be performed first. This procedure would restore the
sagittal mandibular position & benefit the treatment of
mandibles & mid facial regions.
Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the
management of panfacial fractures." British Journal of Oral and Maxillofacial
Surgery 38.5 (2000): 472-476.

35.  Owing to the importance of condylar fractures in the
treatment of PFFs, the condyle is placed in the normal
position before the correction of mandibular fractures
can be ensured.
 In some cases when a parasymphysis fractures occur
with superolateral dislocation of condyle –
1. 1st manual manipulation of the displaced condyle
2. 2nd the reduction of parasymphysis
Li, Zhi, et al. "An unusual type of superolateral dislocation of mandibular condyle:
discussion of the causative mechanisms and clinical characteristics."Journal of oral
and maxillofacial surgery 67.2 (2009): 431-435.

36.  During the treatment of PFFs , the occlusion helps in management &
evaluation of treatment & also provides a reference for the proper
reduction of maxillary factures.
 The excellent contact between the segments from both the labial /buccal &
lingual segments before & during fixation of mandibular fracture is very
important, because even a minimal defects would increase the width of
lower face, resulting in abnormal occlusions & leading to improper
management of maxillary fractures.
Li, Zhi, et al. "Abnormal union of mandibular fractures: a
review of 84 cases."Journal of oral and maxillofacial
surgery 64.8 (2006): 1225-1231.

37.  During the two years 1993–94, 57 maxillary fractures presented
to Parma General Hospital’s Department of Maxillofacial
Surgery.
 9 of the patients underwent treatment of condylar fractures, all
associated with other facial fractures.
Follow-up of 2-3 yrs –
 no evidence of malocclusion , articular dysfunction, open bite or
other skeletal or dental anomalies.
 In all cases, the posterior facial height was restored.
A. Tullio, E. Sesenna. Role of surgical reduction of condylar fractures in
the management of panfacial fractures .British Journal of Oral and
Maxillofacial Surgery, Volume 38, Issue 5, October 2000, Pages 472-476

38.  Asnani et al reported that If there is calvarial
injury sequencing should start caudally and
proceed cranially to achieve optimal results. If
there is remarkable commiuation of mandible
sequencing should start cranially to caudally.
Asnani, Smita Sonavane, Fawaz Baig , Srivalli Natrajan
Usha. Panfacial Trauma - A Case Report. International
Journal Of Dental Clinics 2010;2 (2): 35-38

39.  Gruss et al advised reduction of zygomatic
arch and malar projection first to reestablish
the “Outer facial frame” before NOE or
“Inner facial frame” is reduced.
Fonseca: Walker, Betts, Barber, Powers. Textbook of Oral
and Maxillofacial Trauma, Third Eddition, Vol-1: 360

40. Dongmei He, Yi Zhang, Edward Ellis III, Panfacial fractures: Analysis of
33 cases Treated Late, J Oral & Maxillofacl Surg 65: 2459-2465, 2007.
 When geometry of dental arches is disturbed
Kelly et al suggested reducing hard palate as
guide for mandibular reconstruction.

41.  Merville recommended “Top to Bottom” sequence
in 1974 if NOE was involved in panfacial fracture.
Merville L: Multiple dislocations of the facial
skeleton. J Maxillofac Surg 2:187, 1974.

42.  Most common fracture site – symphysis & condyle.
 Most common type of fracture – isolated linear fracture.
 No correlation in incidence between mandibular fracture & other fractures
in PPF’s was observed.
 PPF’s with simple mandibular fractures – fewer complications & better
treatment effects.
 Significant difference between mandibular fractures in PPF’s & general
mandibular fractures were observed.
 Most of the patients were treated with –
Bottom-up & Outside In & got satisfactory result.
 Small % - difficult to treat – requires comprehensive classification.
RESULT HIGHLIGHTS

43. Considering the important role of the mandible
in facial bones, the results have provided
evidence of the feasibility of the "bottom-up and
outside-in" approach in the treatment of PFFs.
However, some PFFs remain difficult to treat.
Thus, additional studies are necessary.

44. RESOURCES
 Andrew C. Smith, Susan E. Barry, Inferior alveolar nerve damage following removal of
mandibular third molar teeth. A prospective study using panoramic radiography. Australian
Dental Journal 1997;42:3.
 Wenig BL:Otolaryngologic Clinics of North America [1991, 24(1):93-101]
 Dongmei He, Yi Zhang, Edward Ellis III:Panfacial Fractures: Analysis of 33 Cases Treated
:Journal of Oral and Maxillofacial Surgery, Volume 65, Issue 12, December 2007, Pages
2459-2465
 Sawhney CP, Ahuja RB.Faciomaxillary fractures in north India. A statistical analysis and
review of management. Br J Oral Maxillofac Surg. 1988 Oct;26(5):430-4.
 Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast
Surg 16:105, 1989
 Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the
management of panfacial fractures." British Journal of Oral and Maxillofacial
Surgery 38.5 (2000): 472-476.

45. RESOURCES
 Li, Zhi, et al. "An unusual type of superolateral dislocation of mandibular condyle:
discussion of the causative mechanisms and clinical characteristics."Journal of oral and
maxillofacial surgery 67.2 (2009): 431-435.
 Asnani, Smita Sonavane, Fawaz Baig , Srivalli Natrajan Usha. Panfacial Trauma - A Case
Report. International Journal Of Dental Clinics 2010;2 (2): 35-38
 Fonseca: Walker, Betts, Barber, Powers. Textbook of Oral and Maxillofacial Trauma,
Third Eddition, Vol-1: 360
 Merville L: Multiple dislocations of the facial skeleton. J Maxillofac Surg 2:187, 1974.

46. THANK
YOU