Professional Documents
Culture Documents
In Panfacial
Trauma
Shivani gaba
JR-II,OMFS
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
Panfacial fractures
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).
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
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.
(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; 26:783793
Anatomical considerations
Key Landmarks
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
skeleton:
1. Dentalarches
2. The Mandible
3. Sphenozygomatic suture
4. Intercanthal region
Dental arches
When one or both dental arches are intact they can be used to a guide to establish proper
dental width.
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
fixation.
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.
The mandible
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.
Sphenozygomatic suture
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 region
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
Imaging
Before the advent of CT scanning, plain film radiography and
linear tomography were the gold standard for imaging of facial
trauma.
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
ORBITS
Nasofrontal ducts.
Fracture repair should be initiated as soon as the patient's other injuries permit.
Particularly in midfacial fracture repair Paul Mansons 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.
Surgical Approaches
Frontal sinus
Superior part of naso-orbito ethmoid
Medial canthal tendon
Supraorbital rim
Orbital roof
Superior aspect of lateral orbital wall
Zygomatic arch
Mandibular condyle (with
preauricular extension)
Subciliary and transconjuctival incision with
lateral canthotomy
Infraorbital rim
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.
Perinasal incisions
Naso-orbitoethmoid region
Medial canthal tendon
Nasolacrimal sac
Disadvantage: significant scarring occurs
Not required if Bicoronal flap is used
Maxillary vestibular incisions
Maxilla
Zygomaticomaxillary buttress
Cervical incisions
Mandible except for high condylar neck
fractures.
Indicated when anatomic reduction is
Crucial
Comminuted mandibular fractures and
fracture of edentulous and atrophic mandible
Allows the surgeon to visualize the reduction
of the lingual cortex.
Goals
Crucial decision
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
segments.
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
How these approaches came in use with time?
Traditionally, complex reconstruction began with the reestablishment of
occlusion and repair of mandibular fractures. From this foundation, the
upper face was reconstructed.
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
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:
1.Lower face-
occlusal unit-teeth,palate,dentition ,alveoler
process of maxilla and mandible
mandibular units-1.horizontal(basal mandible)-
distal angle,body,symphysis,parasymphysis
2.vertical section-condyle
2.Upper face
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)
First attention
Arch bars.
#of the hard palate are repaired first(rigid) to set the width of the lower central
face.
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. 6
11
7
Check occlusion always 12 14
10
Attention is then directed to the lateral mandible. 8 9
5 13
1
3
Comminuted mandibular fractures are repaired through reassembly 2
of small fragments into larger segments and subsequent linkage and bone 3
grafting when necessary under a sturdy reconstruction plate scaffold. 4
6
11
7
12 14
10
8 9
5 13
1
3
2
3
4
Upper mid face unit:
Central (7)
After the frontal bar has been stabilized, a rigid
horizontal buttress for fixation of nasoethmoid
fractures has been created and its appropriate
relationship to the anterior cranial base has been
restored.
Adequate reduction and fixation of the nasoethmoid
complex, the aesthetic core of the face, is the most
important determinant of upper midfacial width and
the most critical step in complex fracture reconst. (a)
Reconstruction begins with repair of the nasomaxillary
and nasofrontal buttresses.(a) (b) (d)
The medial orbital walls are then reduced and (a)Sequencing of comminuted nasoethmoid fractures begins
repaired with reconst. of the nasomaxillary and nasofrontal
Buttresses
Transnasal reduction of the medial orbital rims is the (b) Transnasal reduct. of the medial orbital rims performed
next step and the most important maneuver in next, wires are placed a/b the tendons and each is properly
controlling midfacial width).(b),(c ) oriented in the a-p plane
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.
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.
BOTTOM UP ,INSIDE OUT TOP-DOWN,OUTSIDE IN
Re-establish the maxillo-mandibular unit as Starting with the reduction and fixation at the level
the first major step of the sequencing of the calvarium and working in a caudal direction
Repair of frontal sinus fracture
Repair of palatal fracture Repair of ZMC(bileteral) # including arches
Maxillomandibular fixation Repair of NOE complex
Repair of mandibular # Repair of le fort including mid palatal split
Repair of condyle # Maxillomandibular fixation
Repair of frontal sinus # Repair of bicondyle #
Repair of NOE complex Repair of mandibular #
Repair of ZMC # including arches
Repair of maxilla
6 1
11 2
7 6
12 14 7 14
10 3 5
8 9 4
5 13 12 8
1 9
3 11
2 10
3
4 13
Top- down ,outside in
Advantage:
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 #
Potential complication:
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.
Bone Grafting and
Soft Tissue Resuspension
Two procedures have improved outcomes in the management of panfacial
trauma:
Primary bone grafting
Resuspension of the soft tissue after extensive exposure of the facial
skeleton
Bone Grafting
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
skeleton.
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
best.
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.
Primary bone graft rigidly
fixed into position to reconstruct the
anterior maxillary sinus wall
including the nasomaxillary
and zygomaticomaxillary buttress
Soft tissue resuspension
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
completely stripped.
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.
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.