Management of Panfacial Fracture

3D-Printed "Jigsaw Puzzle" in Craniomaxillofacial Comminuted Fracture Reduction

BACKGROUND

Surgical treatment of comminuted and multiple facial fractures is challenging, as identifying the bone anatomy and restoring the alignment are complicated. To overcome the difficulties, 3D-printed "jigsaw puzzle" has been innovated to improve the surgical outcome. This study aimed to demonstrate the feasibility of 3D-printed model in facial fracture restoration procedures.

MATERIALS AND METHODS

Patients with traumatic craniomaxillofacial fractures treated at a single institution were enrolled in this study. The exclusion criteria included the presence of mandibular fractures, greenstick fractures, isolated fractures, and revision cases. Fine-cut (1-mm thick) computed tomography images of each patient were assembled into a 3D model for preoperative planning. Major fragments were segmented in virtual surgical planning, printed out with a 3D printer as "jigsaw puzzle" pieces, and assembled with plates and screws as in surgical rehearsals. We further matched our study group with a control group of patients who underwent the corresponding procedures to compare operative time.

RESULTS

Nine patients with craniomaxillofacial fractures were included in the study, including 2 patients with zygomaticomaxillary complex fractures and 7 patients with multiple fractures. No remarkable postoperative complications, such as enophthalmus or optic nerve injury, that require additional or revision surgery were noted. The mean operative time was 391 and 435 minutes in the study and control groups, respectively. The t test results were not statistically significant.

CONCLUSIONS

Surgeons can perform comprehensive preoperative planning, simulation, and obtain a real-time reference for facial bone reduction by using the 3D-printed "jigsaw puzzle" in multiple complicated craniomaxillofacial fractures.

Exploring the correlation of epidemiological and clinical factors with facial injury severity scores in maxillofacial trauma: a comprehensive analysis

Introduction

The Facial Injury Severity Scale (FISS) provides a numerical value based on individual fractures that can be a valuable tool for management of maxillofacial trauma patients. The aim of this study was to evaluate the association of epidemiological and clinical factors with facial fracture patterns and their correlations with FISS.

Methods

A retrospective study was conducted based on 511 medical records from a 4-year period of patients with facial trauma who underwent open reduction internal fixation (ORIF) under general anesthesia. Fracture patterns were categorized into 3 anatomic subunits: upper, middle and lower face. Single-unit and panfacial fractures groups were analyzed separately. Data regarding demographics, hospitalization, etiology of injury, fracture site and complications were collected. The overall risk of fracture within the viscerocranium requiring an ORIF was presented in graphical form.

Results

Single-unit fractures were more typical in younger patients. There was a significant association between FISS score and traumatic etiology, hospitalization time, length of surgery in each group (p < 0.001). For panfacial fractures, FISS >6 indicated prolonged surgery (>2 h) and hospitalization (>1 week).

Discussion

Despite the questionable clinical utility of FISS, classifying maxillofacial trauma can facilitate comprehensive treatment planning and multidisciplinary collaboration, particularly in complex cases such as panfacial fractures.

A paradigm in panfacial fracture treatment to improved dental occlusion

Introduction

The prevalence of maxillofacial fractures is rising due to increased road traffic accidents, necessitating prompt and effective management, especially in cases of panfacial fractures. The primary objective in treating such fractures is to restore occlusion and stabilize midface buttresses and pillars.

Case report

This article presents the case of a 56-year-old male who sustained panfacial fractures following a road accident, exhibiting symptoms including facial pain and nosebleeds. The treatment involved the use of arch bars for dental occlusion. Post-operative recovery was complicated by silent aspiration, successfully managed with a tracheostomy. After one month, the patient showed symmetrical facial features with no abnormalities.

Conclusion

It is crucial to weigh the benefits and limitations of Maxillomandibular Fixation in relation to the specific fracture types. This case underscores the potential of arch bars in improving outcomes for patients with complex facial fractures.

Postoperative Evaluation of Nerve Function Following Coronal Incisions for Facial Fractures: A Clinical Study

AIM

The present study aimed to evaluate the postoperative nerve function following coronal incisions for facial fractures.

MATERIALS AND METHODS

The present study included 30 patients with craniomaxillofacial trauma treated using the bi-temporal/coronal or hemicoronal approach. A preoperative computed tomography (CT) scan of the face with 3D reconstruction was done for all the patients to determine the exact extent of the fractures. All the cases were undertaken with general anesthesia and endotracheal intubation. Under all aseptic conditions, a coronal incision was given, reflection of the flap was done and fracture segments were approached. Reduction and fixation were achieved at the sites and closure was done. Postoperatively, neurological deficits in the zygomaticotemporal, supraorbital, and frontal branches of the facial nerve were closely observed at 1-, 4-, 16-, 24-, and 52-weeks intervals.

RESULTS

In all 30 patients, the duration of recovery varied between 16 weeks, 24 weeks, 32 weeks and 52 weeks but at the end of 32-52 weeks all the deficits subsided. There was a marked recovery between 16 and 24 weeks, with a complete resolution of 52 weeks. The study found a significant association between recovery time and nerve healing, highlighting the coronal approach's effectiveness in treating complex facial fractures while preserving nerve integrity.

CONCLUSION

In conclusion, the study found that while patients undergoing craniomaxillofacial reconstruction via the coronal approach initially experienced notable neurological deficits, full nerve function was ultimately restored over time, underscoring a strong correlation between nerve healing and favorable functional outcomes.

CLINICAL SIGNIFICANCE

The coronal approach not only delivers superior esthetic results but also safeguards neural integrity, minimizing the risk of nerve impairment often associated with traditional methods of fracture management. Coronal incisions provide superior access for precise anatomic reduction and preserve nerve integrity. How to cite this article: Pattnayak A, Awasthi N, Penumatsa NV, et al. Postoperative Evaluation of Nerve Function Following Coronal Incisions for Facial Fractures: A Clinical Study. J Contemp Dent Pract 2024;25(12):1135-1140.

Secondary Reconstruction of Panfacial Fractures With Virtual Reality Surgical Planning Using Both Pre and Postreconstruction Scans

Late secondary reconstruction is sometimes required in patients with suboptimal primary panfacial fracture repair. At this stage, it can be difficult to discern original facial architecture due to malunion and bony remodeling. By utilizing the original postinjury CT scan to complete fracture reduction in the virtual reality (VR) planning environment, the surgeon may attempt to recreate an "ideal" facial bony anatomy for patients. This technique was completed in 2 patients presenting with facial deformity secondary to malunited panfacial fracture. Each had a cone-beam CT (CBCT) scan taken at presentation and the initial postinjury CT scans were obtained. Fracture reductions were completed in VR to recreate the preinjury anatomy. The resulting model was overlaid with current anatomy to create surgical aids. The first patient, a 23-year-old man, presented with malunion of all bones of the midface. Cutting guides were designed for the Lefort 1 segment, left zygomaticomaxillary complex (ZMC), and naso-orbito-ethmoid (NOE) osteotomies. The second patient, a 30-year-old woman, had bilateral ZMC and subcondylar fractures, midface retrusion, and malunion of parasymphyseal fracture. A 2-stage procedure was planned, including an initial Lefort I and bilateral sagittal split osteotomy with midline wedge excision. To address malar projection, a second surgery was planned using custom MEDPOR midface implants for the NOE and zygomatic regions. Both patients were discharged home, and all surgical goals and esthetic objectives were achieved.

Utility of the LeFort I Osteotomy in the Acute Management of Midface Trauma

PURPOSE

Pure and isolated LeFort I, II, and III fractures are rare. Typically, they occur at different levels on each side and may be incomplete in nature, which complicates management. The LeFort I osteotomy is a well-described technique in elective management of midface deformities. However, there is minimal literature on its use in acute trauma. This study describes the use of the LeFort I osteotomy as a surgical maneuver to aid in the reduction of complex midface fractures and the re-establishment of premorbid occlusion.

METHODS

A retrospective review was performed of all consecutive midface fractures managed at our center from 2008 to 2020. The inclusion criteria were adult patients who had a LeFort I osteotomy in the setting of acute fracture management. Primary outcomes were the long-term stability of fracture fixation and the re-establishment of stable, reproducible occlusion at follow-up.

RESULTS

Twenty-two cases met the criteria for inclusion. The most common indication was contralateral LeFort I and ipsilateral incomplete or absent LeFort I (50%). Most remaining cases had a high LeFort (II or III) on the ipsilateral side and a high LeFort I on the contralateral side (41%). There was one case of nonunion requiring revision and bone grafting. In all remaining cases who presented for follow-up at an average of 1.5 years, stable, reproducible occlusion was achieved.

CONCLUSIONS

In acute trauma, a LeFort I osteotomy is a safe and effective technique to re-establish premorbid occlusion when passive reduction of the maxilla cannot be achieved. This technique can be safely added to the armamentarium of any surgeon who manages acute craniofacial trauma.

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.

Motorcycle Accidents are the Strongest Risk Factor for Panfacial Fractures Among Pediatric Patients

Study Design

A retrospective cohort study was conducted using the Kids' Inpatient Database from 2000 to 2014. Subjects were included if they were 18 years and younger and suffered any type of facial fracture.

Objective

The purpose this study was to determine the risk factors for incurring panfacial fractures among the pediatric population.

Methods

The primary predictor variables were a set of heterogenous variables that included patient characteristics, injury characteristics, hospitalization outcomes. The primary outcome variable was panfacial fracture. Logistic regression was used to determine the independent risk factors for panfacial fractures.

Results

Relative to infants and toddlers, teenagers were nearly three times more likely to sustain panfacial fractures (P < .01). Relative to no chronic conditions, patients with one or more chronic conditions were more likely to incur panfacial fractures. Motorcycle accidents were over three times more likely (P < .01) to result in panfacial fractures while car accidents were over two times more likely (P < .01) to result in panfacial fractures. Falls were less likely (OR, .39; P < .01) to result in panfacial fractures.

Conclusions

Motor vehicle accidents was a major risk factor for panfacial fractures. Teenagers are also found to have an increased risk for panfacial fractures relative to infants and toddlers. Each additional chronic condition was a significant risk factor for suffering panfacial fractures relative to not having any chronic condition at all. In contrast, falls independently decreased the risk of incurring a panfacial fractures. Special attention should be given to safety precautions when occupying a motor vehicle.

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.

Blows or Falls? Distinction by Random Forest Classification

In this study, we propose a classification method between falls and blows using random forests. In total, 400 anonymized patients presenting with fractures from falls or blows aged between 20 and 49 years old were used. There were 549 types of fractures for 57 bones and 12 anatomical regions observed. We first tested various models according to the sensibility of random forest parameters and their effects on model accuracies. The best model was based on the binary coding of 12 anatomical regions or 28 bones with or without baseline (age and sex). Our method achieved the highest accuracy rate of 83% in the distinction between falls and blows. Our findings pave the way for applications to help forensic experts and archaeologists.

Contemporary management of complex craniofacial trauma: virtual planning, navigation and the novel thermoformed cage splints in a strategic, sequential, computer-guided protocol

INTRODUCTION

It was the aim of the study to assess if computerized simulation and the use of thermoformed cage splints are useful to plan cases of complex craniofacial trauma.

MATERIALS AND METHODS

patients with fractures in any of the thirds of the craniofacial skeleton and occlusion impairment. Virtual surgical planning with digital reduction of fractures, navigated planning, thermoformed cage splints were used in all cases. Surgical outcomes were evaluated by computing the surface deviation and occlusograms between planned and postoperative models.

RESULTS

13 patients were enrolled in this study. Accuracy of bone repositioning was evaluated compared with the surgical planning. For the mandible, mean Root Mean Square Error (RMSE) was of 1.67 with a standard deviation (SD) of ±0.75 mm (p < 0.001); for the maxilla, average RMSE was of 0.88 with SD of ±0.52 mm (p < 0.001); and for midfacial and upper third bone segments, average RMSE was of 0.59 with SD of ±0.47 mm (p < 0.001) CONCLUSIONS: Within the limitations of the study it seems that thermoformed cage splints might be a promising alternative to other well-established approaches for accurate occlusal restoration and can be fully integrated within the digital workflow.

Postoperative Computed Tomography for Facial Fractures

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

Technical Note on Three- and Four-Wall Orbital Reconstructions with Patient-Specific Implants

ABSTRACT

Orbital reconstruction is one of the most complex procedures in maxillofacial surgery. It becomes even more complex when all references to the original anatomy are lost. The purpose of this article is to provide an overview of techniques for complex three- and four-wall orbital reconstructions. Preoperative virtual surgical planning is essential when considering different reconstruction possibilities. The considerations that may lead to different approaches are described, and the advantages and drawbacks of each technique are evaluated. It is recommended to reconstruct solitary three-wall or four-wall orbital defects with multiple patient-specific implants. Optimizations of this treatment protocol are suggested, and their effects on predictability are demonstrated in a case presentation of a four-wall defect reconstruction with multiple patient-specific implants.

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.

Surgical Dilemmas in Multiple Facial Fractures - Coronal Flap Versus Minimally Invasive: Case Report and Literature Review

The Rationale:

Pan-facial fracture is a complex trauma that involves the upper, middle, and lower third of the facial bones. The surgical management of such complex cases is either by the posterior approach (coronal flap) or anterior approach through local incisions.

Patient Concerns:

This report describes the case of severe pan-facial trauma in a 52-year-old male who sustained a severe pan-facial trauma.

Diagnosis:

He suffered from multiple facial fractures that included: Frontal bone, skull base, Naso-orbitoethmoid (NOE), zygomatic and sub-condylar fractures.

Treatment:

He was managed by minimally local periorbital and lynch incisions.

Outcomes:

Fractures were properly reduced with resultant symmetrical facial dimensions. No postoperative complications were demonstrated including facial nerve function.

Take-away Lessons:

We should consider minimally invasive local incisions in pan-facial fractures when there is no need to restore the frontal sinus and the anterior-posterior dimensions of the zygomatic arch.

Evaluation of Postoperative Sensory and Motor Deficit Following Craniomaxillofacial Reconstruction Using Bicoronal Flap: An Evaluative Study

Introduction:

The ideal surgical approach to treat craniomaxillofacial skeleton should provide maximum exposure of the facial skeleton, ensure less potential for injury to facial structures and allow for good cosmetic result. Several designs have been described such as hemicoronal, preauricular, lateral eyebrow, and bicoronal approach. Although the bicoronal flap gives superior long-term cosmetic results, it has a few disadvantages. We conducted this study to assess neurosensory disturbances and motor deficit following craniomaxillofacial reconstruction using bicoronal flap.

Materials and Methods:

A prospective study was carried out in the Department of Oral and Maxillofacial Surgery, North Karnataka, India. Forty patients with craniomaxillofacial trauma requiring fixation of fracture or reconstruction were included in the study. Postoperative neurosensory evaluation is carried out at intervals of 1 week, 1 month, 3 months, and 6 months clinically using mechanoreceptive and nociceptive testing.

Results:

Among 40 cases, 11 (27.5%) had postoperative paraesthesia affecting the supraorbital region; 9 (22.5%) of them had return of normal sensation within 6 months and 2 (5%) patients became normal after one year. Four patients had unilateral frontalis weakness on the right side for a period of 6 months.

Discussion:

The bicoronal flap is a preferred approach for access to the craniofacial skeleton and orbit with minimal sensory and motor complications. However, before choosing the same, the advantage of raising such a wide flap should be weighted comparing the benefits and complications.

Evaluation of Panfacial Fractures in a German Supraregional Trauma Center between 2015 and 2017 - A Retrospective Study

Introduction:

Panfacial fractures represent the most severe injuries to the face. The combination of these fractures determines the treatment strategy. This study aims to retrospectively review the data of adult patients treated for complex facial skull fractures in a hospital in Dortmund, Germany from 2015-2017.

Materials and Methods:

We extracted related patient data from the hospital electronic repository and reviewed the patient files and radiological images. The fractures were classified based on the AO-Classification. The statistical analysis was performed by descriptive statistical methods. The main goal was to determine the most common fracture combinations.

Results:

A total of 188 patients with panfacial fractures were identified (181 adults, 7 children and adolescents). The gender and age distribution corresponded to the international literature (male-to-female ratio: 3.1:1, most common injuries among young men). 2–9 fracture sites were identified per patient, resulting in a fracture frequency of 3.13 per patient. 69 different fracture combinations have been identified. The most common ones were combinations of lateral and central mid-face fractures, and combinations of nasal bone fractures with lateral midface fractures or nasal bone fractures combined with mandibular fractures. Between 1 and 13 osteosynthesis implants per patient were used for osteosynthesis; the most commonly used plates were 2.0 mm and 1.5 mm straight plates. The average inpatient stay was 3 days (standard deviation [SD] = 3.0 days), and the average operation time (incision to suture) was 39.5 min (SD = 53.5 min).

Discussion:

Panfacial fractures are the most complex maxillofacial injuries. The complication rate in this study (4.5%) is below the international data. The treatment of panfacial fractures requires designated centers with experienced teams and good interdisciplinary cooperation.

Long-term evaluation of treatment protocols for isolated midfacial fractures in a German nation-wide craniomaxillofacial trauma center 2007-2017

An update on the trends in maxillofacial traumatology provides additional information on the actual and changing needs. This retrospective study aimed to review all patient records of patients treated for isolated midface fractures in the Department of Cranial- and Maxillofacial Surgery at the Dortmund General Hospital between 2007 and 2017. The patient radiographs and patient files were reviewed. The safety and efficacy of the applied methods were controlled by assessing complications based on the Clavien-Dindo classification system. The statistical analysis included descriptive methods including regression analysis and χ2-test. In eleven years, 3474 isolated midface fracture sites have been identified in 2868 patients. The yearly trend is slightly increasing, in elderly clearly worsening, in children and youth decreasing. The male-to-female ratio was 2.16:1 for the whole study population, in the age group 18-25 y.o. 6.95:1 while in elderly above 80 y.o. 1:2.51, the age group specific incidence reflects this result, too. The most common fractures were nasal bone fractures (1405), zygomatic fractures (832) and orbital floor fractures (700). The average hospital stay was 2.7 days, the most fractures were operated within 24 h. The complication rate was 2.02% (Clavien-Dindo class II-V). The incidence of midfacial fractures is increasing in the total population and especially in elderly, but decreasing in children. Development of injury prevention measures is needed in this population. The diagnostic and therapeutic procedures are appropriate, as there is a low complication rate and short inpatient stay observed.

Experience with Airway Management and Sequencing of Repair of Panfacial Fractures: A Single Tertiary Healthcare Appraisal in Najran, Kingdom of Saudi Arabia - A Retrospective Study

Introduction:

Special cooperation is required among surgeons and anesthetists in airway management during repair of panfacial fractures, due to problems of shared airway and occlusion. Several methods have been proposed for airway management and sequencing of repair of panfacial fractures. The main objective of the current study was to share our experience in the airway management and sequencing of repair of panfacial fractures.

Methods:

This was a retrospective study of panfacial fractures in the Kingdom of Saudi Arabia from January 2008 to December 2018. Data collected included demographics, type of airway management, sequence of repair (as primary variables), and outcome of surgery (secondary variable), while surgeon and anesthetic expertise are confounders. Data were analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY, USA: IBM Corp). Results were presented as simple frequencies and descriptive statistics. Pearson Chi-square was used to compare categorical variables such as airway management and sequencing of repair with the panfacial fractures. Statistical significance was set at P ≤ 0.05.

Results:

Overall, 1057 patients sustained different categories of maxillofacial bone fractures with 23 females and 1034 males (M:F of 46:1). A total of 43 male patients out of 1057 patients had panfacial fractures during the study period, giving a prevalence rate of 4.1%. Only the 43 male patients with panfacial fractures were analyzed. All cases were as a result of motor vehicular accident. Six (13.9%) patients had tracheostomy while 37 (86.1%) patients had submental intubation. “Bottom-up” and “outside-in” approach was used in 33 (76.7%) patients, while “top-bottom” and “inside-out” approach was used in 10 (23.3%) patients.

Discussion:

Submental intubation was the major airway management of panfacial fracture, and “bottom-up” and “outside-in” approach was the main sequence of repair in our series. These approaches have been mentioned in the literature.

Conclusion:

From our study, victims of pan-facial fractures were found to be exclusively male with MVA as the sole etiological factor. Barring severe head injuries, which may necessitate the use of tracheostomy to sustain breathing over a longer period, submental intubation is extremely reliable as a mode of airway management during surgical treatment of panfacial fractures. The sequencing of repair of panfacial fractures can only be determined according to the case presentation rather than a predetermined one.

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.

Assessment of Panfacial Fractures in the Pediatric Population

PURPOSE

Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population.

PATIENTS AND METHODS

We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected.

RESULTS

We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival-or before arrival-at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died.

CONCLUSIONS

Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.

A novel fixation method for panfacial fracture using an Ilizarov-type external fixator

In general, internal plate fixation is mainly performed in order to reduce multiple facial bone fractures and rarely uses an external fixator. Although it would be ideal to successfully achieve or preserve the occlusal relationship of the upper and lower jaws, it is difficult to successfully manage multiple bone fragments in order to use them to achieve internal fixation, especially when treating a severely comminuted facial fracture. In addition, it is also important to prevent the onset of severe infection after sub-periosteal dissection, due to the presence of avascular bony fragments and an internal fixation implant which thus represents a foreign body. In order to treat extensive comminuted fracture without internal plate fixation, we performed external fixation using an Ilizarov-type external fixator. The Ilizarov-type external fixator is characterized by a few circular external structures and threaded rods. This device can be modified for use in the field of orthopedic surgery to correct three-dimensional deformities caused by fragile complicated fractures and bone defects. The advantages of the Ilizarov-type external fixator for treating panfacial fractures include a low invasiveness, utility in various fracture situations, easy adjustment of threaded rods, and a low potential cost. We herein report the first case of a severe panfacial fracture that was successfully treated using an Ilizarov-type external fixator.

[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.