2. Historic Perspective
•Panfacial fractures are defined as those involving the upper, middle, and lower thirds of the face.
•Result of high velocity trauma
•Prior to rigid fixation, these fractures were treated with wire fixation and head frames. Difficult
to establish and maintain the 3D stability of the facial skeleton.
4. Anatomic Considerations
Vertical Buttresses: Nasomaxillary, zygomaticomaxillary & pterygomaxillary buttress
Nasomaxillary & zygomaticomaxillary buttresses are reconstructed, but the pterygomaxillary
buttress is not because of inaccessibility.
Condyle & posterior mandibular ramus make another buttress that establishes the posterior
facial height.
5. Anatomic Considerations
Vertical and horizontal buttresses give the facial skeleton its structural integrity.
Bone is usually thicker over the buttresses to neutralize the forces of mastication or impact.
With proper reduction of these buttresses, we are able to reconstruct the height, width and
projection of the face
6. Key Landmarks
Known landmarks and anatomy can be used to reconstruct more precisely those areas that have
been damaged.
Dental Arches
Mandible
Sphenozygomatic Suture
Maxillary buttress
Intercanthal Region
7. Dental Arches
Widening of the entire facial complex can occur if segments are not properly reduced
For example, did palatal split and the mandible fracture along tooth bearing region w/
associated condylar fractures
8. The Mandible
Reduction of both the buccal and lingual cortical surfaces prior to fixation yields better results
Bilateral subcondylar fractures: must be treated to establish the posterior facial height.
When b/l subcondylar fractures are present with an associated fracture along the symphysis/or
body region, the mandible may splay, with a resultant increase in facial width.
9. Sphenozygomatic Suture
Sphenozygomatic suture along the internal surface of the lateral orbital wall is a key landmark
for both the reduction and fixation of the zygomaticomaxillary complex when the orbital roof
and superior lateral orbit are intact.
Orbital roof and superior lateral orbit are rarely fractured, they are accurate landmarks
Once the zygoma is in the proper place, the location of the maxilla can be verified.
If significant bone loss, consider bone grafting.
10. Intercanthal Region
Intercanthal region may be used to reestablish midfacial width since the intercanthal distance is
fairly constant in the adult facial skeleton.
Restoration of the proper intercanthal distance via reduction of the naso-orbitoethmoid
complex can help to determine facial width.
13. Bone Grafting
It has improved outcomes in the management of panfacial trauma
For significant defects, the use of bone grafting to prevent soft tissue collapse and to allow for
structural support of the facial skeleton.
14. Airway Management
Extensive head injuries w/ prolonged intubation anticipated: tracheostomy
Nasal intubation would be difficult due to extensive injuries to LF fxs. Also access to the frontal
sinus and naso-orbitoethmoid region is hindered.
Oral intubation: No indication for MMF
15. Fracture Management
Goal is to restore the anatomy in all 3 dimensions, plating the maxillofacial buttresses wherever
necessary
Two options for sequencing:
◦ Re-establish the maxillo-mandibular unit as the first major step (BOTTOM-UP)
◦ Starting with the reduction and fixation at the level of the calvarium and working in a caudal direction
(TOP-DOWN)
19. TOP-DOWN
Starting with the reduction and fixation at the
level of the calvarium and proceed in a caudal
direction with reduction and fixation.
20. Re-establishing the maxillo-mandibular
unit as 1st priority
Le Fort I fracture but no sagittal split of the palate
and no mandibular fracture: establishment of the
maxillomandibular unit with arch bars and MMF
21. LeFort fracture, no sagittal
split of the palate and
mandibular fractures:
establishment of the correct
mandibular dental arch via
intact maxillary dental arch
through MMF
22. Le Fort type fracture, a sagittal split of
the palate and no mandibular fractures,
the mandibular dental arch may be used
as a guide in reestablishing the occlusion
& width of the maxillary dental arch w/
placement of arch bars & MMF
23. Le Fort type fracture, sagittal split of the
palate together with mandibular fractures,
reestablishment of the proper width of the
disrupted dental arches is more difficult.
Must reconstruct one dental arch and use it
as a template for the other.
25. Dental impressions, making dental models, perform model surgery to establish premorbid occlusion.
Palatal splints/mandibular splints fabricated.
26. In cases where there are condylar fractures,
open treatment of these fractures will
restore proper mandibular height and chin
position.
27. Proper maxillo-mandibular unit
restored, next step is to begin
the reduction and fixation of
the remainder of the midface
starting from the calvarium and
working in a caudal direction
28. Sequencing from the calvarium down
The reconstruction sequence to
reestablish midfacial buttresses and
dimensions starts with the most reliable
reference structrues and on the side
with the least comminution
First priority is to address
calvarial,frontal sinus and orbital roof
fractures
Using the calvarium as the foundation
for the remainder of the midface
reconstruction , the surgeon progresses
from this level to the Le Fort I level.
29. Proper alignment of the zygomatic arch and the infraorbital rim must be taken into consideration
during the reduction of the various fractures
Completion of the reconstruciton of the periorbital areas is performedby addressing the NOE
and nasal fractures.
Where reconstruction of the medial canthal tendon is necessary, it is the final step before wound
closure
30. Next step: Midface reconstruction across Le
Fort I
Fractures at Le Fort I level should align, if not, need to reassess the other fracture alignments
and consider a correction.
Minimal malalignment at the Le Fort I level is not as noticeable as a malalignment of the orbits
MMF, mandibular fracture repair
31.
32. Complications
Widening of the facial complex- failure to properly reduce key areas. To prevent this, the
surgeon must use stable segments, known landmarks, and anatomic reduction.
Scarring, edema, sensory dysfunction, motor dysfunction, TMJ dysfunction
Unfavorable esthetic and functional outcome with secondary deformity
