Reference point and confirming
points; two important guides in treatment of panfacial Fx.: 3 case
reports
Abstract
We present 3 cases of Panfacial fractures through which we try to
emphasize two important sequencing rules: “Reference point”(the most
intact area to determine the starting point for fixation) and the
“Confirming points” ( the points which should be checked out to
confirm the exact position & orientation).
Key words: skull fracture, fracture fixation, internal
Key clinical message
It’s important to achieve and stablish a correct occlusal relationship
parallel with repositioning of other fracture segments in facial
skeleton, resulting rehabilitation of facial esthetic in treatment of
Panfacial fractures using correct sequences
Introduction
Panfacial fractures are defined as multiple facial bone fractures
including the upper, middle, and lower thirds of the face(1), which in
most cases are associated with loss of soft- and hard tissue and some
sequela such as blindness. (2).
Even in early management, the exact reduction and repositioning of
fracture segments to their pre-traumatic position is very complicated
and challenging especially in comminuted one (3).
In this matter, various sequences of reduction are offered:”
Bottom-to-top”, “Top-to-bottom”, “Inside-out”, and
“Outside-inside” are the most common concepts of sequence in
management of panfacial fractures in which the elected sequence is based
on factors such as the pattern of fracture and the experience of surgeon
(4).
The most widely used concepts are “Bottom-to-top &
Outside-to-inside”; i.e After mandibular reconstruction as a strong
buttress, and stablishing the maxilla over mandible, other facial
compartments including zygomatico-orbital complex will be
reconstructed(4).
In this article, we presented 3 patients with emphasis on two concepts
including “Reference point” and “Confirming points” that act as a
guide to reduce the facial contour and improves surgical procedure.
Reference point is defined as the intact point around the fracture area
from which the reduction will start and ascertain the sequence of the
reduction and fixation. For example, if in a total orbital
reconstruction, the only intact area is medial part of the infraorbital
rim, this point could be the reference point and reconstruction will
obey the sequence of Inside-outside.
The other concept is confirming points which indicate the areas that
should be checked out – and of course should be reduced and fixed- in
order to become sure that the tridimensional orientation of the facial
complex is precise. We have three confirming points for the midface: ZS
suture (zygomatico-sphenoid suture), Root of zygomatic arch and
zygomatic buttress.
Case Report I
A 19-years-old male patient has been referred to Maxillofacial surgery
ward of Sina hospital with diagnosis of panfacial fracture due to motor
vehicle accident (MVA) 1.5 months before referral.
The clinical findings were as follows:
1. Loss of right mandibular premolars, 2. Right comminuted ZMC fracture,
3.Right comminuted Mandibular body fracture, 4. Right hemi Lefort I
fracture, 5. Right Coronoid fracture, 6. Right ectropion due to severe
multiple facial scars, 7. Severe Malocclusion and 8. Paresis of right
Facial nerve. 9. Malnutrition as the sequela of the trauma (Fig-1 &2).
in order to decrease the operation time , because of malnutrition of the
patient, treatment plan was planned to be in two phases in a way that
treatment of ZMC fracture was postponed to second phase.
In the first phase, via the vestibular approaches in maxilla and
mandible and also through old facial scar, we had an access to the
fractures in Maxilla and Mandible. The arch bars were placed and fixed
over the dentition in both jaws and also two IMF screws was placed in
right molar area of mandible.
After osteotomy and removal of callus from the fracture segments in
mandible and maxilla and mobilization of segments, intermaxillary
fixation was done. For fixation we started with the simplest fracture
area; i.e. Hemi Le fort I fracture with the aid of a miniplate placed at
pyriform rim. After that, a mandibular plate was used at mandibular body
for fixation. The gap in the fracture site of mandibular body was filled
with coronoid process, which had been osteotomized, and callus and
grafts were fixed with a miniplate.
At the end scar revision was done.
At the following photos, you can see the
Pre- and Post-operative CT scans
and clinical views (4months thereafter) of the patient (Fig-3&4).
The second surgical phase was done 4 months after the first phase (5.5
month after trauma):
In this phase, the approaches were hemicoronal, transconjunctival
(retroseptal) and maxillary vestibular. In this patient the intact area
was upper face so the most suitable area to start fixation or the
Reference point was frontozygomatic suture (ZFS).
On the other hand, ZFS has to be reduced and fixed based on the
Confirming point adjacent to it: zygomaticosphenoid suture (ZS). In
other words, the position of ZS suture would confirm the accuracy of
reduction at ZFS and its tridimensional orientation. In this case, due
to defect at ZS suture, we didn’t have this confirming point and not
only we had to rely on other Confirming points for exact orientation of
ZMC, but also we had to reconstruct the
Lateral Orbital wall with titanium
mesh to prevent postoperative enophthalmos (Fig-5).
After fixation of zygomaticofrontal suture, horizontal pillars should be
reconstructed. The first horizontal pillar was zygomatic arch that was
fixed with the aid of a microplate in order to prevent postoperative
pseudozygomatic arch bowing. Root of zygomatic arch in cases, which
fracture line is located at posterior part of arch, has to be checked
out as the second Confirming point (Fig-6).
The second horizontal pillar was Inferior Orbital rim. In this case,
medial orbital wall was intact so internal orbital reconstruction was
done only to cover the defect at Orbital floor with titanium mesh and
temporal fascia placed over it,
paying attention to Orbital axis and the edge of defect (Fig-7).
Next the large defect from infraorbital rim up to maxillary alveolar
process in anterior wall of maxillary sinus was covered with another
Titanium mesh.
The third confirming point is Zygomatic buttress that was fixed using a
mini plate. After that ORIF at pyriform rim was repeated.
Finally, Zygomaticus Major muscle was suspended with 2-0 Nylon suture.
The following photos show the
comparative CT scan (Pre- and
Post-operative) (Fig-8).
Nine months after the second surgery, the third surgery was scheduled.
The problem list was: 1. Right Zygomatic arch bowing (was diagnosed 2
months post-op), 2. Depression at right Temporal fossa and 3. Mild right
enophthalmos (Fig-9).
The approaches were hemicoronal and transconjunctival (retroseptal)
approaches.
Intraoperatively we found out fracture of microplate over the zygomatic
arch and separation of bone segments; that’s why zygomatic arch bowing
was manifested 2 months postoperatively.
The treatment plan was as follow: at first the plates at zygomatic arch
and zygomaticofrontal suture were removed and the segments of Zygomatic
arch was re-fixed was with two miniplates. Internal Orbital
reconstruction was adjusted by releasing of soft tissue from titanium
mesh and adding a double-layered medpore. Finally,
temporal depression was augmented
with two sheets of medpore (Fig-10).
You can see the final results in the following photo (Fig-11).
Case Report II
A 25-years-old male patient was referred to Maxillofacial surgery ward
of Sina hospital with diagnosis of panfacial fracture due to motor
vehicle accident (MVA) one month before referral.
The clinical findings were as follows: 1. No light perception at right
eye, 2. Scar over the dorsum of the nose, 3. Telecanthus with 40 mm
intercanthal distance, 4. Saddle nose and 5. Mild enophthalmus (Fig-12).
In summery we had: right Lefort II fracture, left Lefort I fracture and
Lefort III fracture, undisplaced palatal fracture, nasoorbitoethmoidal
(NOE) type II fracture, frontal bone (glabella) fracture and comminuted
nasal bone fracture (Fig-13).
For this patient (just like the 1st. case) we
preferred to use submental intubation and the approaches were bicoronal
approach, vestibular approach for maxilla, bilateral transconjunctival
approach (retroseptal + Lat. Canthotomy) and H- type approach over the
nose including old scar on the nose.
The concept of “Top to bottom” and “Inside to outside” was selected
so initially upper midface including glabella & dorsum of the nose were
reconstructed. For this aim two nasal bones and frontal processes of
maxillary bone were fixed to frontal bone using microplates then other
segments of nasal bones were fixed with another microplates. Then with
the aid of a 0.4 mm SS wire (creating bur holes at the Med. orbital
walls and passing the wire like a mattress suture), we constricted and
elevated the NOE complex in order to deal with telecanthus. Then we
grasped the Med. canthal tendon at each side with the 2-0 Nylon suture
and fixed it to the contralateral plate in order to have a support for
the ligaments. You can see all these procedures in the following photos
with indicating the wire and the sutures with purple flashmarks. Final
intercanthal distance was decreased to 35mm. In next step
Frontozygomatic suture and Lateral Orbital wall were fixed, paying
attention to Zygomaticosphenoid sutures as a confirming point and after
that right and left inferior orbital rims were fixed (Fig-14).
Since bilateral zygomatic arches were relatively not displaced, the next
step was fixation of left
Zygomatic buttress and right
Pyriform rim (Fig-15).
Consequently, a monocortical calvarial graft was harvested in order to
elevate the nasal dorsum. This graft was then covered with
temporal fascia & was fixed on
its place using suture passing through upper lateral cartilage and over
the graft (Fig-16).
In the following photos you can compare the
Pre- and Post-operative CT scans
(Fig-17).
Case Report III
A 37-years-old male patient was referred to Maxillofacial surgery ward
of Sina hospital with the diagnosis of Panfacial Fx. due to motor
vehicle accident (MVA) 5 days before referral.
According to clinicoradiographic findings, the pattern of the fracture
was as follows: Symphyseal Fx, Lefort I Fx, Right Lefort II Fx, Left
Lefort III Fx. Maxillary and Mandibular dentoalveolar Fx.s, and Frontal
bone Fx.
Some degree of pure blow out fracture was seen & sagittal cut of CT
scan revealed a spur-shaped bone fragment resulting restriction of
ocular muscle movement (Fig-18).
First mandible has been reduced and fixed as a Reference point. In other
words, after reduction of dentoalveolar fractures in both jaws with the
aid of Arch bar and IMF, the fracture line at symphysis was exposed via
Vestibular approach and was reduced and fixed with 2 miniplates. At
upper- and midface we preferred to have the concept “Up to bottom”.
Via Bicoronal approach, frontal B., nasofrontal suture and ZFS were
exposed, reduced and fixed. Then with a wire we stablished a bone
fragment at sup. Orbital rim. Next step was doing ORIF over pyriform rim
& zygomatic buttress via vestibular approach.
Finally, internal orbital reconstruction of left eye was done through
transconjunctival approach and a sheet of Porex was inserted in orbital
floor to cover the defect. The postoperative photographies were obtained
2 months after operation.
At the following photos you can see the intraoperative and postoperative
photos of the patient and compare the Pre- and Post-operative CT scans
(Fig-19 to 21).
Discussion
There are different etiological factors for panfacial fractures
according to geographical, socioeconomical and cultural characteristics
of the society (5, 6). In our society motor vehicle accidents & motor
cycle accidents are the most common causes.
The main goal in treatment of panfacial fractures is repositioning of
fracture segments and reconstruction of previous facial contour and more
importantly occlusion(7).
There are various concepts regarding sequencing at reduction & fixation
of fracture segments in managing a panfacial Fx. (1). Furthermore there
are different approaches for exposure and fixation based on experience
of the surgeon(8). Some surgeons considered reconstruction of occlusion
as the first step in treatment and begin with mandible. Therefor they
pay attention to vertical height of the face by restoring the situation
of maxillomandibular unit and then the rest of the face.
In fact they follow the sequence of “Bottom to top” (9).
On the other hand some surgeons addresses establishing facial width to
reconstruct facial projection and consequently establishing the facial
height, following the concept of “Inside to outside”(2).
An important point in reduction of maxillofacial skeleton is paying
attention to the horizontal and vertical pillars of the face that make a
strong framework for face and a good pathway to transmit the mastication
forces (10). These pillars which should be reduced properly and
stabilized firmly (1). No matter which concept has been chosen, the
exact three-dimensional orientation of face has to be checked out by
confirming points .
Conclusion
In this study, we have tried to emphasize the importance of “Reference
point and Confirming points” in term of reduction and fixation of
fracture segments besides the “concepts of sequencing” through 3
cases. Although choosing the most conservative approaches to expose the
fracture segments has always been the priority of surgeons, management
of panfacial fracture needs more aggressive approaches.
Author Contribution:
Mehrnoush Momeni Roochi: study concept, study design, manuscript editing
and review
Narges Hajiani: manuscript preparation, editing and review
Sayna Nezaminia: manuscript preparation.
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