Why Should We Start From Mandibular Fractures in the Treatment of Panfacial Fractures?

Risk of complications in panfacial bone fracture according to surgeons: A meta-analysis

BACKGROUND

Panfacial bone fractures pose intricate challenges because of severe fragmentation and the loss of landmarks. Surgeons use a variety of reduction techniques, including bottom-up and top-down approaches. This single proportional meta-analysis explores sequencing differences and complications between oral and maxillofacial surgery surgeons (OMSs) and plastic and reconstructive surgeons (PRSs) in treating panfacial bone fractures.

METHODS

The PubMed and Scopus databases were searched systematically, and we compiled 14 studies published between 2007 and 2023 involving 1238 patients. A systematic review of the included studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and data on the reduction techniques; total complication rates; and rates of malocclusion, enophthalmos, infection, asymmetry, and esthetic complications were collected.

RESULTS

The bottom-up technique was the most prevalent for both types of surgeons (57.1%, 8 out of 14). Malocclusion rates (I2 = 0% for OMSs and 41% for PRSs) were similar between the groups (p = 0.72), but PRSs tended to have a lower enophthalmos rate (I2 = 0% for OMSs and 32% for PRSs) than OMSs (p < 0.01). Infection rates remained consistent across all studies. However, high heterogeneity was observed for the total complication rate (I2 = 94% for OMSs and 85% for PRSs) and asymmetry and esthetic complications (I2 = 88% for OMSs and 92% for PRSs), making direct comparison between the two groups inconclusive.

CONCLUSIONS

In this study, the differences in surgical techniques and levels of interest have a greater impact on the outcomes of the panfacial bone fracture than the surgeon's specialty. However, more in-depth studies are needed to accurately pinpoint panfacial bone fracture reduction trends and differences in postoperative complications in the two expert groups.

Pediatric Panfacial Fractures

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Sequencing of panfacial fracture surgery: a literature review and personal preference

BACKGROUND

Treating panfacial fractures (PFFs) can be extremely difficult even for experienced surgeons. Although several authors have attempted to systemize the surgical approach, performing surgery by applying a unidirectional sequence is much more difficult in practice. The purpose of this study was to review the literature on PFF surgery sequence and to understand how different surgical specialists-plastic reconstructive surgery (PRS) and oral maxillofacial surgery (OMS)-chose sequence and review PFFs fixation sequence in clinical cases.

METHODS

The PubMed and Google Scholar databases were scoured for publications published up until May 2020. Data extracted from the studies using standard templates included fracture part, fixation sequence, originating specialist, and the countries. Bibliographic details like author and year of publication were also extracted. Also, we reviewed the data for PFFs patients in the Trauma Registry System of Dankook University Hospital from 2011 to 2021.

RESULTS

In total, 240 articles were identified. This study comprised 22 studies after screening and full-text analysis. Sixteen studies (12 OMS specialists and 4 PRS specialists) used a "bottom-top" approach, whereas three studies (1 OMS specialist and 2 PRS specialists) used a "top-bottom" method. However, three studies (only OMS specialists) reported on both sequences. In our hospital, there were a total of 124 patients with PFF who were treated during 2011 to 2021; 64 (51.6%) were in upper-middle parts, 52 (41.9%) were in mid-lower parts, and eight (6.5%) were in three parts.

CONCLUSION

Bottom-top sequencing was mainly used in OMS specialists, and top-bottom sequencing was used at a similar rate by two specialists in literature review. In our experience, however, it was hard to consistently implement unidirectional sequence suggested by a literature review. We realigned the reliable and stable buttresses first with tailoring individually for each patient, rather than proceeding in the unidirectional sequence like bottom-top or top-bottom.

Application of Computer-Aided Design and Individualized Templates for Bilateral Zygomaticomaxillary Complex Fractures

PURPOSE

Reduction of the bilateral zygomaticomaxillary complex (ZMC) fracture with individualized templates based on computer- aided surgical simulation system. To evaluate the practicality and accuracy of this approach in the treatment of bilateral ZMC fracture.

METHODS

Sixteen patients with bilateral ZMC fractures were collected to create a study model. The authors reconstruct the ZMC on one side via the three-dimensional (3D) model, and then mirrored to the opposite side. Multiple individualized templates were made based on the 3D model, and used as intraoperative guidance to reduce fractures. After surgery, the facial symmetry and the position of zygoma were observed. The mouth opening, pupil level, and sensation of infraorbital nerve were evaluated. Some mark points on zygoma were measured and the postoperative horizontal asymmetry rate (H) was calculated. Besides, orbital height and width were measured.

RESULTS

For all patients, the position of bilateral ZMC was basically restored. The patients with restriction of mouth opening all recovered to normal. The H values were less than 3.0% at all mark points. There was almost no difference in bilateral orbital width and height. Meanwhile, there was no significant difference between the preoperative measurements of the ideal virtual 3D model and the postoperative measurements of patients.

CONCLUSIONS

The study proves that application of computer-aided design and individualized templates can accurately guide the reduction operation of ZMC fracture, restore the ideal shape of ZMC, and obtain good facial symmetry.

Repairing Facial Fractures with Interrupted Maxillary-mandibular Arches by Computer-assisted Reverse Planning Model Surgery

Background:

Management of comminuted facial fractures with maxillary-mandibular arch interruption is difficult, resulting in inadequate bone reduction and malocclusion. Traditionally, a good quality dental splint is helpful, but difficult to obtain in acute trauma. We apply a computer-assisted design and three-dimensional printing technology to improve splint fabrication and utilization, thus facilitating restoration of dental occlusion and facial fracture.

Methods:

We retrospectively reviewed patients who suffered from facial fractures with interruption of the maxillary-mandibular arches. We developed the “computer-assisted reverse planning and three-dimensional printing model surgery” algorithm and applied it in selected patients. An occlusal splint was created as a surgical guide to enhance the maxilla-mandibular unit repair by taking care of the bone reduction and occlusion. All included patients were followed up to assess the functional outcome and patients suitable for this method.

Results:

From Jan 2015 to Aug 2020, 10 patients (eight men and two women) with comminuted facial fractures were included. The average time of surgery was 9.2 days. The average follow-up time was 8.6 months. There was no patient who needed major revision to correct malocclusion or facial asymmetry.

Conclusions:

A computer-assisted design splint decreases intraoperative inaccuracies and difficulty in comminuted maxillo-mandibular fractures. It is a useful and reliable alternative. Collaboration with an experienced engineer and patient selection are indispensable in delivering successful outcomes. Patients who have more than three bone fragments in a single dental arch or more than four bone fragments in the entire maxillary-mandibular unit appear to be excellent candidates for this method.

Pattern and presentation of panfacial fractures at a tertiary reference center based in Central Kerala, South India

Aim: We aimed to describe the pattern and clinical presentation of panfacial fractures and to analyze if the panfacial fractures differ from other maxillofacial injuries concerning the time of intervention and duration of hospital stay, thereby evaluating if panfacial fractures place a burden on our hospital which is a tertiary reference center in South India. Materials and methods: This was a prospective study conducted for a duration of two years from January 2018 to January 2020 among 28 patients who reported with panfacial fractures. Descriptive data were entered and chi-square test was done to find out the association between categorical variables. Results: Patients who reported with panfacial fractures were young adults (n = 17, 60.7%), males (92.8%) predominantly. Among those with a history of Road Traffic Accidents (n = 23, 82%), 91% (n = 21) did not use any protective devices. Conclusions: Males, young adults, use of two-wheelers, consumption of alcohol before driving, and avoidance of protective devices were most commonly associated with panfacial fractures (p < 0.05). Based on the study, panfacial fractures place a burden on the hospital in terms of the need for special care and prolonged stay period and operating time compared to other maxillofacial injuries (p < 0.05).

Management of Panfacial Trauma: Sequencing and Pitfalls

Panfacial trauma refers to high-energy mechanism injuries involving two or more areas of the craniofacial skeleton, the frontal bone, the midface, and the occlusal unit. These can be distracting injuries in an unstable patient and, as in any trauma, Advanced Trauma Life Support (ATLS) protocols should be followed. The airway should be secured, bleeding controlled, and sequential examinations should take place to avoid overlooking injuries. When indicated, neurosurgery and ophthalmology should be consulted as preservation of brain, vision, and hearing function should be prioritized. Once the patient is stabilized, reconstruction aims to reduce panfacial fractures, restore the horizontal and vertical facial buttresses, and resuspend the soft tissue to avoid the appearance of premature aging. Lost or comminuted bone can be replaced with bone grafts, although adequate reduction should be ensured prior to any grafting. Operative sequencing can be performed from top-down and outside-in or from bottom-up and inside-out depending on patient presentation. All protocols can successfully manage panfacial injuries, and the emphasis should be placed on a systematic approach that works from known areas to unknown areas.

Classifying and standardizing panfacial trauma according to anatomic categories and Facial Injury Severity Scale: a 10-year retrospective study

Background

The purpose of this study was to identify the epidemiologic factors of panfacial fractures (PFs), and to evaluate the significance of anatomic PF categories and the Facial Injury Severity Scale (FISS) in classifying and standardizing panfacial injuries.

Methods

A retrospective review of all patients treated with PFs at our institution between June 2010 and April 2021 was performed. PF was defined as a concurrent fracture in at least 3 of 4 facial subunits (frontal, upper midface, lower midface, and mandible). Data regarding patient demographics, causes of injury, location of fractures, major concomitant injuries, and postinjury complications were collected, and the FISS score was collected from each patient. Statistical analysis was performed using IBM SPSS Statistics version 22.0.

Results

A total of 227 patients were enrolled. The most commonly fractured bones were the maxillary sinus wall (92.1%), mandible (82.8%), and zygomatic arch (75.3%), and the most common fracture sites in PFs were graphically presented. Four PF patterns were defined: FULM (n = 60), FUL (n = 39), ULM (n = 127), and FUM (n = 1). There was a significant association between PF patterns and sex (p = 0.018), the number of concomitant injuries (p = 0.014), and early surgical airway management (p = 0.003). Different PF patterns were significantly correlated with different types of concomitant injuries and complications. The FISS score showed a significant difference with PF patterns (p = 0.000) and sex (p = 0.007), and a FISS value of 11 or more is the appropriate cutoff for the prediction of multiple concomitant injuries and complications.

Conclusions

Both the anatomic PF categories and FISS were significantly correlated with various concomitant injuries and complications. The combination of PF categories and FISS provided a better positive and negative prediction of concomitant injuries and complications for PF patients. Patients with FULM and FISS > 11 had an obviously higher proportion of the need for multiprofessional treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01900-w.

Versatility of Hard Occlusal Splints in Optimizing Outcomes in Patients with Old Pan-facial Fractures

Pan-facial fracture repair is considered one of the most challenging complex reconstructive procedures to perform. It is always better to treat facial fractures as soon as possible. A delay of several days or weeks makes an ideal anatomic reduction difficult, if not impossible.

Splitting and Splaying Apart of the Craniomaxillofacial Skeleton by Medially Directed Disruptive Forces of Unusual Etiologies- A Case Series

Introduction

Extreme forces directed towards the centre of the facial region can produce devastating injuries, with disruption of the mandible, maxilla and naso-orbito-ethmoid complex, with or without frontal bone involvement. The magnitude and trajectory of the force and nature of the impacting object, dictate the degree of displacement and comminution of the craniomaxillofacial skeletal components, as well as the extent of soft tissue loss sustained.

Diagnosis & Challenges

To elucidate various challenges faced in the management of four cases of extreme craniomaxillofacial injuries, caused by centrally directed forces of rather unusual etiologies, namely, a traversing bullet, a bamboo rod, a heavy iron cattle tethering peg and a metal electrical pole. In each of the cases, the force of impact resulted in splitting and splaying apart of the facial skeleton, with a resultant increase in its transverse width, and an ensuing severe facial deformity and functional debility.

Rationale & Interventions

A ߢBottom-up, Outside-in' surgical sequence was employed to carry out reduction, fixation and reconstruction of the deranged maxillofacial skeletal architecture and restoration of the soft tissue morphology.

Outcomes & Lessons

The transverse dimensions of the flared out facial frames could be re-established and restored to their pre-trauma status successfully in all the cases, thereby achieving excellent esthetic and functional outcomes. Despite the extensive and serious nature of the injuries sustained, gross residual craniofacial defects, deformities and asymmetries, as well as debilitating functional deficits, could be effectively and successfully averted.

Comparison of Maxillofacial Fractures Between Pedestrians and Passengers in Road Traffic Accidents

PURPOSE

Road traffic accidents remain as the most common cause of maxillofacial injuries in developed countries. To the best of our knowledge, comparative analysis of fracture localizations and injury types of injured pedestrians and passengers is seldom performed. Thus, this study aimed to compare maxillofacial injuries between pedestrians and passengers injured in road traffic accidents in terms of demographic characteristics of the patients, localization of fractures, and treatment.

MATERIALS AND METHODS

The study population was composed of patients who underwent surgery for maxillofacial fractures resulting from road traffic accidents. They were divided into the pedestrian group and passenger group. Demographic data, fracture sites, and treatment methods were investigated retrospectively.

RESULTS

Most of the patients were 20 to 30 years of age. Isolated mandible fractures occurred in 55.71% of the pedestrian group and 43.78% of the passenger group. Panfacial fractures were observed in 5.71% (n = 8) of the patients in the pedestrian group compared with 14.28% (n = 21) in the passenger group.

CONCLUSIONS

Based on the injury pattern and mechanism of in-vehicle accidents, fractures tend to be located in the middle and upper facial bones rather than in the mandible. Thus, careful management in triage is important, as each group has specific injury patterns. Patients with panfacial fractures require meticulous management because they are at risk for high-energy injury and comorbidities.

Maxillofacial injuries in pregnancy following domestic abuse: A challenge in management

Domestic violence against women remains one of the most difficult obstacles in the growth of civilization. The maxillofacial region is commonly involved, and injuries are complex to characterize and manage due to diverse presentations, underlying physiological changes and sometimes an association with pregnancy complications, creating a challenge for the operating surgeon. This case report discusses the clinical presentation of maxillofacial injuries sustained by a pregnant woman who also had obstetric complications. The management of such trauma by a multidisciplinary squad led by the maxillofacial surgery team is outlined. Increasing awareness among oral healthcare providers for the early identification of interpersonal abuse along with timely intervention and adequate referral is important. Close monitoring and follow-up are also mandatory.

Sequencing of Fixation in Panfacial Fracture: A Systematic Review

Objective

In panfacial fracture management, the controversy still exists in the sequencing of fixation. The purpose of this systematic review is to establish the best sequence pattern which assists in achieving definite facial width, vertical height and anteroposterior projection.

Methods

The review was conducted according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. Two independent authors performed a comprehensive search of the PUBMED, EBSCO, J-Gate, SCOPUS and NDH for articles published up until December 2018. Sequence of fixation, timing of intervention, outcome, follow-up period and complications were evaluated for patients with panfacial fracture.

Results

In total, 202 articles were identified from the databases. After screening and full text analysis, 25 studies were included in this systematic review. Nineteen studies reported bottom-to-top sequence and two studies reported top-to-bottom approach. However, four studies reported both the approaches. The follow-up period ranges from 3 weeks to 4 years.

Conclusion

Based on the literature support and evidence, good and satisfactory outcome achieved in "Bottom-top and outside-in" sequence when compared with other sequence pattern. Early repair of panfacial fracture is advised for proper reduction and fixation, but can be delayed in accompanying life-threatening injuries. Complications are perceptible in all the sequences; it can be avoided by definitive treatment planning and stepwise management.

Treatment of Panfacial Fractures and Three-Dimensional Outcome Analysis: The Occlusion First Approach

Successful management of panfacial fractures requires an understanding of the component fracture patterns and the ability to relate them anatomically to the stable elements of the skull. However, there is no widespread agreement on the ideal approach to treatment of panfacial fractures and several techniques have been proposed. Here, the authors suggest the "occlusion first" approach, a technique that involves larger segment reduction as the initial step to provide an appropriate occlusal plane.This retrospective study included data from patients undergoing open reduction and internal fixation of panfacial fractures between March 2005 and November 2017 by the occlusion first technique. The degree of reduction in the mid and lower face was evaluated using 3D CT. The causes of injury, combined fracture, and multidisciplinary consultation during postoperative management were reviewed.The study population comprised 61 patients (47 male, 14 female) with a mean age of 47.6 years (range, 9-76 years). Analysis of 3D CT scans obtained from 42 patients showed no significant difference in hemifacial volume in the postoperative period (left hemifacial volume: 206.48 ± 68.35 cm, right: 205.17 ± 66.27 cm, P = 0.436).The occlusion first approach, with initial reduction of larger segments, enables effective reconstruction of the multiple segments involved in panfacial fractures. The authors have demonstrated that this technique successfully restores the entire face, improves surgical reduction, acts as an orientation aid during surgery, and provides a template for the smaller segments. Therefore, this approach can facilitate the accurate and efficient reduction and fixation of panfacial fractures.

Surgical Management of Double/Triple Mandibular Fractures Involving the Condylar Segment: Our Perspective

A series of surgical cases operated in our unit are considered to analyze and evaluate the different techniques and sequencing employed in the surgical management of double/triple mandibular fractures involving a condylar fracture. Deviating from the normal sequence of reducing and fixing the dentate segment first, we addressed the condylar segment first. A combination of different approaches for different cases such as a periangular with a vestibular, a preauricular and a retromandibular with a vestibular were used according to the type of fractures. The accessibility to one difficult case with a medially displaced condyle was facilitated by using Hegar's uterine dilators. In all cases, good anatomical reduction was achieved with stable occlusion and without any signs of facial nerve impairment. The 'Condyle first' approach in the surgical management of double/triple mandibular fractures, is a reliable and efficient technique.

Panfacial Bone Fracture and Medial to Lateral Approach

Panfacial bone fracture is challenging. Even experienced surgeons find restoration of original facial architecture difficult because of the severe degree of fragmentation and loss of reference segments that could guide the start of facial reconstruction. To restore the facial contour, surgeons usually follow a general sequence for panfacial bone reduction. Among the sequences, the bottom-to-top and outside-in sequence is reported to be the most widely used in recent publications. However, a single sequence cannot be applied to all cases of panfacial fractures because of the variations in panfacial bone fracture patterns. In this article, we intend to find the reference and discuss the efficacy of inside-out sequence in facial bone fracture reconstruction.

Surgical Approaches and Management of Panfacial Trauma: A Case Report

Patients with multiple fractures involving upper third of the face, the mid-face and the lower third are generally referred to as Pan-facial fractures and managing these cases is extremely complicated. Proximity of the maxillofacial region to the important features or senses such as visual function (diplopia), olfaction, respiration (airway management), chewing or mastication (occlusion), deglutition and aesthetics; makes the scenario a little more complex for the surgeon operating in this particular region than the surgeon operating any other part of the body. Inability to directly visualize and reduce all the components of a pan facial injury along with inadequate stability of the fractured bones leads to persistent deformity. It is challenging to follow an established pattern for repairing the pan facial fractures. Each case with this type of fracture is unique and requires skill and expertise of the surgeon to restore the pre-traumatic anatomy and facial aesthetics. Despite all the aggressive treatment, most of the patient's with pan facial trauma may have some residual deformity which may require another correction surgery later. This article briefs about the management and simple approaches used to reduce and fix a case of pan facial trauma in a 23-year-old male.

A Comparative Prospective Study of Two Different Treatment Sequences i.e. Bottom Up-Inside Out and Topdown-Outside in, in the Treatment of Panfacial Fractures

PURPOSE

To compare the sequence bottom-up inside-out with top-down outside-in, in the treatment of pan facial fractures and to evaluate the outcome of these approaches.

PATIENTS AND METHODS

The data from 11 patients with panfacial fracture are prospectively analysed. Five cases are treated with bottom-up approach and six patients with top-down approach.

RESULTS

There were 11 male patients (six in top-down approach and five in bottom-up approach), ranging in age from 24 to 50 years. All injuries were result of RTA (n = 11, 100 %). Final treatment outcome was excellent in 3 (50 %), 1 (16 %) good and 2 (32 %) cases were fair in topdown approach, 3 (60 %) excellent and 2 (40 %) fair in bottom up approach with contingency coefficient value (P < .632) which was insignificant. There was no significant deviation from the two groups in the final treatment outcome.

CONCLUSION

Within the limitation of low sample size we found that both bottom-up inside-out and top-down outside-in approaches have similar clinical outcomes. Hence it could be suggestive to start fixation of least disrupted (more stable) facial half as a guide for reconstruction of the remaining. Choice of the bottom-up inside-out or top-down outside-in sequence should be according to the pattern of fractures and preference of the surgeon. However, further controlled clinical trials, comparative studies with a larger sample size would be better to evaluate the final clinical outcome of individual techniques.

The mandibular symphysis as a starting point for the occlusal-level reconstruction of panfacial fractures with bicondylar fractures and interruption of the maxillary and mandibular arches: report of two cases

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation.

Panfacial fractures: an approach to management

Panfacial fractures are defined as fractures involving the lower, middle, and upper face. Treatment can be challenging and requires an individualized treatment plan. A firm understanding of the treatment principles of each individual fracture is necessary before attempting to tackle the patient with panfacial fractures. Advances in rigid fixation, wide exposure, primary bone grafting, and attention to soft tissue reattachment have significantly improved the treatment of the patient with panfacial fractures.