MANAGEMENT OF PANFACIAL FRACTURES.

1. MANAGEMENT OF PANFACIAL FRACTURES. GODWIN T. AROTIBA

2. INTRODUCTION. Fractures concurrently involving the upper, middle and lower 1/ 3rd of the face. Complex facial fractures that concurrently involve the following bones : Frontal bones, zygomatico-maxillary complex, naso-orbitoethmoid region, maxilla and mandible.

3. Usually result from high velocity trauma Prior to the advent of rigid fixation these fractures were treated with wire fixation and head frames � difficult to establish and maintain the three dimensional stability of the facial skeleton- poor results. Advances in the management of maxillofacial trauma have resulted in better results : High resolution CT scan Rigid fixation techniques Soft tissue resuspension Primary bone grafting

4. Etiology Motor vehicle collisions Assault Sports related accidents Gunshot wounds

5. OBJECTIVES OF TREATMENT To re-establish facial form & function: Occlusion � myofascial pain and TMJ pain Restoration of patency of the nasal cavity. - prevention of nasal obstruction, sinusitis and obstructive sleep apnea. Also essential for good quality of speech. 3. Restoration of orbital volume � prevent development of enophthalmos and diplopia 4. Restoration of facial height, width and projection-prevention of facial deformities-essential for psychological and social well- being of the individual

6. APPLIED ANATOMY

7. FACIAL BUTTRESSES Vertical buttresses: a.Nasomaxillay- maxillary process of frontal bone+frontal process of maxilla. b.Zygomatico-maxillary-zygomatic process of frontal bone +lateral orbital rim+lateralzygomatib body +zygomatic process of maxilla. c. Pterygomaxillary �pterygoid plates of the spenoid and maxillary tuberosities. d. The condyle and posterior mandible make up the 4th vertical buttress establishing posterior facial height. Usually, a. and b. are reconstructed, c. is not easily accessible and is therefore not reconstructed.

8. Horizontal buttresses: (anterior-posterior buttresses) a. Frontal buttress �supraorbital rims and glabellar region. b. Zygomatic buttress �zygomatic arch, body and orbital rim. c. Maxillary buttress �basal bone of the maxilla. d. Mandibular buttress �basal bone of the mandible.

9. The bone is generally thicker over these described areas to neutralize forces of mastication and impact. Proper reduction of these buttresses allows the surgeon to restablish facial height, width and projection.

10. 4. KEY LANDMARKS 4 known landmarks that can be used to reconstruct more precisely those areas that have been damaged: 1. Dental arches 2. The Mandible 3. Sphenozygomatic suture 4. Intercanthal region

11. 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 open reduction and rigid fixation (plating) �when there is a solitary midpalatal split. ? When there in comminution 2.Take impressions for fabrication of dental models.Perform simulated surgery on upper and lower arches and fabricate a surgical splint. NB*** 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.-a very robust bone that can be anatomically reduced if attention is paid to detail.

12. 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)

13. Sphenozygomatic suture Situated along the internal surface of the lateral orbital wall. Is a key landmark for reduction and fixation of the zygomaticomaxillary complex provided the orbital roof and lateral orbit are intact. The zygomatic buttress is important is important in establishing the proper position of the zygoma and or maxilla. If there is gross bone loss in this are, primary bone grafting may be indicated to reestablish the buttress.

14. 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

15. 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 can be made; now 0.75mmaxial cuts with coronal reconstructions is possible (allows 3-D reconstructions if needed and decreases the number of repeat scans)

16. 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

17. SURGICAL APPROACHES. Designed to achieve wide exposure of the fracture lines which is essential for accurate anatomic reduction.

18. Bicoronal flap 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)

19. Subciliary and subconjuctival incision with lateral canthotomy Infraorbital rim Medial and lateral orbital wall Orbital floorfrontozygomatic suture (with lateral canthotomy)

20. Upper eyelid crease incision Superior and lateral orbital region Frontozygomatic suture Not required when the bicoronal flap is used

21. Perinasal incisions Naso-orbitoethmoid region Medial canthal tendon Nasolacrimal sac Disadvantage: significant scarring occurs Not required if bicoronal flap is used

22. Maxillary vestibular incisions Maxilla Zygomaticomaxillary buttress

23. mandibular vestibular incision Mandible from ramus to symphysis Not recommended for comminuted fractures

24. Cervical incisions Mandible except for high condylar neck fractures. Comminuted mandibular fractures ed fracture of edentulous and atrophic mandible Indicated when anatomic reduction is Crucial Allows the surgeon to visualise the reduction of the lingual cortex.

25. Bone grafting Two procedures have improved outcomes in the management of panfacial trauma: Primary bone grafting Soft tissue resuspension Bone loss may occur in buttress and �non-buttress� areas of the face particularly with high velocity trauma. Significant bone loss should be repaired by bone grafting to prevent soft tissue collapse. Even when the bone graft becomes exposed, secondary wound healing generally occurs. Areas that may require primary bone grafting include: frontal bone, nasal dorsum, orbital floor, medial orbital wall, zygomaticomaxillary buttress. Calvarial bone is the best source of bone graft. Bicoronal flap [rovides direct access and resists resorption better than endochondral bone. Rigid fixation of these grafts have been reported to decrease the rate of resorption.

26. soft tissue resuspension To prevent sagging of the soft tissue with reattachment at a more inferior level. Particularly important in mid face fractures where the soft tissue attachment is usually completed stripped. Two steps for reattachment: 1. refixation of the periosteum or fascia to the skeleton 2. Closure of the periosteum, muscle fascia and skin where incisions have been made. The periosteum is inflexible and limits and limits soft tissue lengthening and migration. Its reattachment is usually accomplished by drilling holes in key locations to fix the periosteum to the bone: -malar eminence -medial and lateral canthi -mentalis muscle

27. Areas where periosteal closure should be obtained include: -frontozygomatic suture. -infraorbital rim -deep temporal fascia -muscle layers of mandibular and maxillary incisions.

28. SEQUENCE OF TREATMENT Airway Management. Fracture Management.

29. Airway Management. A very important decision in panfacial fracture management is how to maintain the airway. Options: 1.Tracheostomy 2. Oral intubation 3.Submental intubation

30. Tracheostmoy Extensive head injuries. Prolonged intubation is anticipated To facilitate management of multiple facial fractures. NB***:In panfalcial fractures, the naso-orbito-ethmoid region is usually involved making nasal intubation difficult and hazardous. Furthermore, with nasal intubation surgical access to the frontal sinus and naso-orbito-ethmoid region is poor/impedded.

31. Oral intubation When maxillo-mandibular fixation is either not possible or not indicated.

32. Submental intubation. When prolonged intubation is not anticipated. NB***: If an extra oral approach is indicated to manage mandibular body/angle/symphysial facture, sub mental intubation may impede surgical access.

33. FRACTURE MANAGEMENT To achieve good results for these complex multiple fractures, treatment must be properly sequenced/arranged. 2 classic approaches: �Bottom up and inside out� (?concentric circles). �Top down and outside in�

34. �Bottom up and inside out� 1. Tracheostomy 2. Repair of Palatal fracture. 3. Maxillomandibular fixation. 4.Repair of condylar fractures 5. Repair of mandibular fractures.(body/symph./ramus). 6.Repair os zygomaticomaxillary complex fracures( including arches). 7. Repair of frontal sinus fracture. 8.Repair of naso-orbitoethmoid complex. 9.Repair of maxilla

35. �Top down and outside in�  1.Tracheostomy 2.Repair of frontal sinus fracture 3.Repair of bilateral zygomaticomaxillary complex( including arch) fracture. 4.Repair of orbito-ethmoid fracture. 5.Repair of Le Fort fracture (including midpalatal split). 6. Maxillomandibular fixation. 7.Repair of bilateral subcondylar fracture 8. Repair of mandibular fracture (symph./body/ramus).

36. NBs*****