Panfacial fractures

how to manage panfacial fracture

1. PANFACIAL FRACTURES JAMEEL KIFAYATULLAH

2. PANFACIAL FRACTURES involve fractures of each of the upper, middle, and lower thirds of the face complex fractures that can result in collapse of facial dimensions as well as malocclusion concomitant ocular, cerebral, and c-spine injuries, as well as multisystemic trauma throughout the body

3. Main goals in panfacial trauma The main goals in panfacial trauma to reestablish the anteroposterior projection, facial height, width, and symmetry along with a functional occlusion.

4. Goals in panfacial truama The horizontal and vertical buttresses of the facial skeleton are key areas of focus in accomplishing this. In addition, the zygomatic arch is a critical buttress in anteroposterior projection as well as prominence of the cheeks.

5. A pproaches Several approaches have been used for the treatment of panfacial trauma: top-to-bottom bottom-to-top the outside-in

6. Surgical technique ( panfacial ) Preoperative planning: Preoperative CT imaging intraoperative CT scanning and navigation Prep and patient positioning supine position on the operation table the upper and middle face is kept exposed submental intubation technique tracheostomy

7. Surgical approach and procedure INCISIONS: coronal access to upper and midface fractures and the zygomatic arches periorbital incisions where indicated both intraoral and extraoral approaches to the maxilla and mandible.

8. Bottom to top Approach The mandible is addressed first use of occlusal splints to restore the occlusion if there are any condylar fractures, they must be reduced first to restore the lower posterior facial height and width ORIF of the fractures may be indicated Following fixation of the mandible, the maxilla is placed into occlusion with the mandible and maxillomandibular fixation is applied to create a maxillomandibular unit.

9. Bottom to top Approach This complex can then be fixated to the rest of the skull base to the correct vertical dimension . The zygomaticomaxillary buttress is often the best and most reliable site for fixation. Once the maxillomandibular unit is reduced and fixated, the middle and upper facial thirds will follow.

10. Top to bottom/outside in Advocated by Gruss and Phillips the establishment of the outer facial frame first and then basing the remaining fixation off this stable frame mainly focuses on the reduction and projection of the zygomas , including the zygomatic arches as well as the frontal bar The surgeon then works inward, reconstructing the NOE complex and eventually the orbits if indicated. From this point the maxilla and mandible can be fixated to this reestablished facial frame.

11. Immediate postoperative care medical management of the patients and their medical comorbidities , monitoring for bleeding, and checking laboratory values if significant blood loss was encountered during the operation Persistent CSF leak, neurologic decline, and signs or symptoms of infection are important points of inspection postoperatively monitor the patient’s eyes and vision if orbits involved

12. Immediate postoperative care Ophthalmologic complications, such as enophthalmos and ectropion , as well as traumatic telecanthus , saddle nose defect, and scarring, are important considerations Inspection of soft tissues

13. Rehabilitation and recovery Functional occlusion must be reestablished in all facial fractures and aggressive rehabilitation of mouth opening early on is recommended. Patients with intracranial injuries may also require long-term rehabilitation at specialized facilities Patients with frontal sinus fracture also require long-term follow-up indefinitely to monitor for signs of mucocele / mucopyocele , brain abscess, and osteomyelitis

14. Rehabilitation and recovery A CT scan should be taken every 5 years after the first year of follow-up and endoscopic techniques may also be used for postoperative monitoring control of soft tissue scarring:big problem Application of a larger nasal splint and/or use of lead plates may assist in soft tissue adaptation to the underlying bones