Severe panfacial fracture with facial explosion: integrated and multistaged reconstructive procedures

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.

Concomitant injuries and complications according to categories of pan-facial fracture: a retrospective study

PURPOSE

The purpose of this study was to investigate concomitant injuries and complications in patients with panfacial fracture (PF) according to patterns of PF.

MATERIALS AND METHODS

PF is defined as fractures involving at least three of the four facial parts (frontal, upper midface, lower midface, and mandible). The data for this study were retrospectively analysed. A simple regression analysis, Cramer's V analysis, and Pearson's correlation analysis were used for verifying significance and correlation between the investigated factors and patterns of PF. Short-term postoperative surgical complications were classified according to the Clavien-Dindo classification (CDC).

RESULTS

There was a statistically significant association between age and PF pattern (ULM: 44.9 ± 19.2; FUL: 42.0 ± 16.8; FULM: 33.6 ± 15.3; FUM: 65; p = 0.024), between the cause of injury and PF pattern (p = 0.047), and between operative time and fracture pattern (ULM: 4h 45min ± 2h 21min; FUL: 5h 19min ± 2h 54min; FULM: 7h 19min ± 4h 13min; FUM: 2h 15min ± 0; p = 0.008). 89% of patients had concomitant injuries in other body parts. In the CDC grade groups, rade IVa cases (n = 4) showed statistically significant differences with PF patterns (p = 0.006). Of all the patients, 58.6% (n = 58) complained of postoperative complications.

CONCLUSION

PF patients can have different fracture patterns, depending on age and cause of trauma. Consequently, different PF patterns have different types of concomitant injuries and complications. PF patients with frontal area fracture have higher CDC grades, and may need ICU care. Therefore, classifying PFs will be a first step towards a systemic approach for treating and reducing complications.

Orbital Fractures in Childhood

Pediatric orbital floor fractures exhibit distinctive features that distinguish them from orbital injuries seen in the adult population. This is mainly due to different anatomy and mechanical properties of the orbital bones in children. The management of pediatric orbital floor fractures requires consideration of these factors, including the age of the patient and therefore child's growth potential, using, if possible, a minimally invasive surgical approach. The aim of this paper is to report a case of a 1-year-old male child with a surgically treated blowout fracture of the orbital floor. To enable early diagnosis and treatment, accurate physical examination is mandatory, but a computed tomographic examination is important, especially in younger patients because of their inability to fully express their symptoms and poor compliance. We discuss the specific presentation and diagnostics of orbital floor fractures in early childhood and the related surgical planning and treatment.

Transnasal Endoscopic Approach for the Treatment of Medial Orbital Wall Fractures

The aim of this study is to report a case series of blowout fractures of the medial orbital wall that were treated endoscopically. Isolated fractures of the medial orbital wall are uncommon and can be asymptomatic. Various surgical methods for repairing medial orbital wall fractures have been described. The standard approach for the treatment of medial orbital wall fractures is the transcutaneous approach or the transconjunctival with retrocaruncular approach. In the last years, the attention on the use of minimally invasive techniques such as transnasal endoscopic approach is growing. This was a retrospective study of six cases completely managed endoscopically. In the presented case series, the endoscopic endonasal approach represented a safe and effective procedure for the reduction of medial wall orbital fractures.

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.

[Frequency and management of complex facial fractures-an oral and maxillofacial surgical assessment]

INTRODUCTION

The treatment of facial fractures is an integral part of the oral and maxillofacial surgical treatment spectrum. In the case of complex fractures that involve multiple levels of the facial skeleton associated with severe concomitant injuries, an individual and interdisciplinary treatment approach is needed, which requires the infrastructure of a national trauma center.

OBJECTIVE

The aim of this study was to analyze the incidence and management of patients with complex facial fractures and considering the concomitant injury pattern.

MATERIAL AND METHODS

A retrospective analysis of patients with complex facial fractures during the years 2009-2015 admitted to the emergency surgical department of a national trauma center was carried out. The identification of appropriate patient cases was based on the International Statistical Classification of Diseases and Related Health Problems (ICD) coding of electronic patient data. Only patients with at least a combination of mandibular and midfacial fractures (2-level fractures) were considered. Patients with mainly dentoalveolar fractures and simple nasal bone fractures were not included. The evaluation of the electronic medical records included the etiology, fracture pattern, associated severe injuries on the basis of the injury severity score (ISS), treatment regimen as well as the length of the hospital stay.

RESULTS

In the 7‑year study period, 3382 patients were identified with facial fractures. Of these, 128 patients (3.78%) presented with a complex fracture pattern with a combination of mandibular fractures and fractures of the midface. The majority of these patients (n = 92) had less severe concomitant injuries (ISS ≤ 16), while 36 patients showed severe concomitant injuries (ISS > 16). The incidence of a 3-level fracture involving the mandible, midface and anterior skull base was only 0.47% and could be detected in 16 patients, of which 10 were classified as polytrauma (ISS > 16).

CONCLUSION

The incidence of complex fractures of the facial skeleton was comparatively low with almost 4%. More than one in four patients with complex injury patterns of the facial skeleton exhibited severe concomitant life-threatening injuries, necessitating an interdisciplinary management with the specialized infrastructure of a nationwide trauma center.

Using the "bottom-up and outside-in" sequence for panfacial fracture management: does it provide a clinical significance?

Panfacial fractures usually refer to simultaneous facial fractures, which affect the upper, middle, and lower thirds of the face. The management of panfacial fracture is complex because of the lack of reliable landmarks. Literature has shown many approaches for management of panfacial fractures. Every segment of bone has a precise function in the repair. Therefore, the "bottom-up and outside-in" sequence is the most widely used approach in the management of panfacial fractures. These facial fractures present remarkable challenges for both experienced and inexperienced surgeons. This article aimed to report a case of a panfacial fracture (mandibular condylar and symphysis fractures associated with an atypical Le Fort III fracture) in a 48-year-old man. The patient was successfully treated using bottom-up and outside-in sequence by accessing all facial injuries. Postoperatively, radiograph examination revealed good reduction and fixation of titanium plates, and physical examination revealed good functional and esthetic outcomes.

Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis

The goal of this retrospective study was to evaluate the efficacy of panfacial fracture repair and to review guidelines for treatment based on AO/Arbeitsgemeinschaft fuer Osteosynthesefragen Association for Study of Internal Fixation theories of biological osteosynthesis. Sixty-eight patients with panfacial fractures were subjected to preoperative X-ray cephalometric analysis and model surgery, followed by open surgical reduction, rigid internal fixation and at least 8 weeks of clinical follow up. A variety of surgical approaches were used, with the 68 patients undergoing a total of 93 surgical procedures. In all but eight patients, the treatment produced satisfactory correction of maxillofacial deformities and restoration of normal function. Among the eight patients whose treatment was not deemed successful, there were two whose facial deformities were not corrected by treatment. In addition, there were five patients with enophthalmos or motor disturbance of the eye that failed to show improvement during the study, and four patients who exhibited signs of limited mouth opening and malocclusion. The systematic and sequential choices of surgical methods were key factors in determining panfacial fracture treatment outcomes. We propose that treatment of bone fractures must take into account the biological characteristics of the damaged bone to facilitate selection of appropriate plate and screw systems and repositioning methods.

Repair of Bone Defects Treated with Autogenous Bone Graft and Low-Power Laser

Because bone healing at the graft site is similar to a fracture repair, the purpose of the present study was to evaluate the effects of low-power laser irradiation on the repair of rat skull defects treated with autogenous bone graft. A defect measuring 3 mm in diameter was produced in the left parietal bone and filled with an autogenous bone graft obtained from the right parietal bone. The animals were divided into 3 groups of 20 rats each: nonirradiated control, irradiated with 5.1 J/cm, and irradiated with 10.2 J/cm. The laser (2.4 mW, 735 nm, 3.4 x 10 W/cm, 3-mm spot size) was applied three times per week for 4 weeks. Greater volume of newly formed bone was observed in the irradiated group with 10.2 J/cm. In both irradiated groups, a greater volume of newly formed bone occurred only in the first 2 weeks. The results demonstrated that laser irradiation at the grafted site stimulated osteogenesis during the initial stages of the healing process in a skull defect of the rat and that this effect was dose dependent.