Management of Panfacial Fracture

Abstract

Traumatic panfacial fracture repair is one of the most complex and challenging reconstructive procedures to perform. Several principles permeate throughout literature regarding the repair of panfacial injuries in a stepwise fashion. The primary goal of management in most of these approaches is to restore the occlusal relationship at the beginning of sequential repair so that other structures can fall into alignment. Through proper positioning of the occlusion and the mandibular-maxillary unit with the skull base, the spatial relationships and stability of midface buttresses and pillars can then be re-established. Here, the authors outline the sequencing of panfacial fracture repair for the restoration of anatomical relationships and the optimization of functional and structural outcomes.

Keywords: facial trauma; occlusion restoration; panfacial fracture; sequencing repair; spatial relationships of midface and mandible.

Fig. 1

Fracture pattern consistent with midface impact. Soft tissue will follow the bone position with widening and flattening.

Fig. 2

Facial widening, open-bite deformity, and flattened facies are shown.

Fig. 3

Midface was not repaired and the occlusion not restored. The midface collapsed with a class III relationship.

Fig. 4

The medial and lateral zygomaticomaxillary buttresses have thicker bone stock for fixation. The central area over the maxillary sinus is thin and usually fractured, so it does not lend to screw fixation routinely.

Fig. 5

The posterior buttresses include the central sphenovomerine and lateral pterygomaxillary components.

Fig. 6

Palate fractures need to be closed and held in position. This example depicts opening the fracture and placing a three-dimensional plate. The fracture may rotate slightly, but will not distract. Mandibular–maxillary fixation will restore the occlusion.

Fig. 7

The patient's head is held in position and the Rowe disimpaction forceps are placed in the mouth and nose. The maxilla is pulled out. Care must be taken to avoid injury to the skull base and propagation of a cerebrospinal leak.

Fig. 8

Mandible fractures are normally repaired via intraoral incisions. With severe facial trauma, external incisions facilitate the repair and also minimize the risk of intraoral dehiscence. The lingual cortex is readily seen and reduced.

Fig. 9

The mandible and maxilla need to be restored prior to the mid- and upper-face correction. This example shows the mandibular–maxillary unit working together en bloc.

Fig. 10

The subcondylar fracture can be repaired to restore the spatial relationship with the skull base. The image shows repair of the subcondylar fracture via a retromandibular approach.

Fig. 11

The frontozygomatic bone has the strongest point of fixation, but is least reliable for reduction. The lateral wall (zygomaticosphenoid junction) is plated. This is the key to anatomical reduction of a complicated zygomaticomaxillary complex fracture and can be held in reduction with a plate, as shown.

Fig. 12

The temporalis muscle is retracted exposing the zygomatic process of the temporal bone. The bone stock is thick and will accept a 10-mm-length screw.

Fig. 13

Comminuted naso-orbito-ethmoid fractures are easily repaired with bone graft and transnasal wiring. The paired wires are twisted to close down the bone and narrow the intercanthal distance.

Fig. 14

Preoperative and postoperative three-dimensional scans show the goal for reduction of the fractures. This is the same patient shown in Figure 2.