CLASSIFICATION, CLINICAL FEATURES OF PAN FACIAL TRAUMA INCLUDING FRACTURE MANDIBLE,MIDFACE, NOSE AND FRONTAL BONE

1. CLASSIFICATION, CLINICAL FEATURES
OF PAN FACIAL TRAUMA INCLUDING
FRACTURE MANDIBLE,MIDFACE, NOSE
AND FRONTAL BONE
Presented by- Dr. Nishant
Kumar

2. • Pan facial fractures are defined as those
involving the upper, middle, and lower thirds
of the face.
• Involve the frontal bones,
zygomaticomaxillary complex, naso-
orbitoethmoid region, maxilla, and mandible.

3. Epidemiology
• Pan facial fractures result from impact from high-energy
mechanisms.
• Such high-energy forces directed at the craniofacial region
result in secondary vectors of injury or contre-coup forces,
which necessitate a high degree of suspicion for other injuries.

4. Features of panfacial fractures
• Most frequently caused by motor vehicle collisions and gunshot
wounds
• Approximately 4% to 10% of all facial fractures
• 80% have condylar neck or intracapsular fractures
• More likely to involve comminuted and avulsed segments
• Lower Glasgow Coma Scale score (average GCS 10)
• Higher hospital complication rate (18%)
• 20% chance of cervical spine injuries

5. Classification
• Mandibular fracture classification
• Midface fracture classification
• ZMC fracture classification
• NOE fracture classification
• Frontal bone fracture classification

6. Classification of mandibular fractures

7. Kruger’s general classification
• SIMPLE / CLOSED
• COMPOUND / OPEN
• COMMUNITED
• COMPLICATED / COMPLEX
• IMPACTED
• GREENSTICK
• PATHOLOGICAL

8. simple-no communication with exterior or interior
Compound-communication through skin externally
through mucosa or PDL

9. Communited - splintering
crushed multiple pieces
Violent forces / high velocity - fire arm / missiles
Complicated / complex- damage to vital structures
Complicates treatment

10. • Impacted – One fragment driven firmly into the other
Clinical movement not appreciable
• Greenstick - One cortex broken and other bent
Incomplete fracture- common children-
resilience

11. Pathological
Generalised skeletal
disease
Localised skeletal
disease
Osteoporosis, pagets,
osteomalacia
Osteomyelitis, cysts, ORN

12. • A fractures not involving basal bone
Eg- dentoalveolar
• Fractures involving the basal bone
i. Single unilateral
ii. Double unilateral
iii. Bilateral
iv. Multiple
Rowe and killey classification

13. Dingman and natwig classification
A. SYMPHYSIS #
B. CANINE REGION #
C. BODY OF MANDIBLE #
D. ANGLE REGION #
E. RAMUS REGION #
F. CORONOID REGION #
G. CONDYLAR #
H. DENTOALVEOLAR #

14. Relation of fracture to the site of injury
DIRECT
FRACTURES
Indirect fractures
(Countercoup)

15. Direction and Favorability of treatment
Horizontally Favourable Fracture line runs
downward and forward so upward
displacement avoided
Horizontally Unfavourable Fracture line
runs Down Wards and Back Wards so
upward Displacement unrestricted

16. Vertically favorable Vertically unfavorable
Fracture line runs from the outer
buccal plate obliquely backwards
and lingually , medial movement
restricted
Fracture line runs from the inner
lingual plate obliquely backwards and
buccally , medial movement
unrestricted

17. Fractures of the midface
Lefort classification
Given by the French surgeon Rene Le-fort In
1901

18. Also called :
• Guerins fracture
• Floating fracture
•Pterygomaxillary dysjunction
• Horizontal fracture
There is complete separation of the dentoalveolar
part of maxilla and the fragment is held only by soft
tissues.
Lefort I fractures

19. Also called:
• Pyramidal #
•Sub zygomatic #
Lefort II fracture has a pyramidal appearance on the pa
skull . Maxilla is separated from the skull base .
Lefort II fractures

20. Also called :
• Transverse fracture
• Supratympanic #
• High level #
•Cranio-facial dysjunction
Lefort III fractures

21. Modified LeFort Fracture Classification - 1993
Le-Fort Level
 I
 la
 II
 IIa
 IIb
 III
 IIIa
 IIIb
 IV
 IVa
 IVb
 IVc
Description
Low maxillary fracture
Low maxillary fracture with multiple segments
Pyramidal fracture
Pyramidal fracture and nasal fracture
Pyramidal and NOE fracture
Craniofacial dysjunction
Craniofacial dysjunction and nasal fracture
Craniofacial dysjunction and NOE
II or III fracture and cranial base #
+ Supraorbital rim fracture
+ Anterior cranial fossa and supraorbial rim#
+ Anterior cranial fossa and orbital wall#

23. Rowe and williams classification -1985
A. Fractures not involving occlusion :
I. Central Region :
F. ractures of the nasal bones/nasal septum.
- Lateral nasal injuries
-Anterior nasal injuries
b.Fractures of frontal process of maxilla
c. Nasoethmoidal fractures
d.Fractures of type (a), (b) and (c) extending
into the frontal
bone (frontoorbitonasal dislocation).
II. Lateral region:
Fractures involving the zygomatic bone, arch and maxilla
excluding dentoalveolar component.

24. B. Fractures involving occlusion :
Dentoalveolar
Subzygomatic
- Lefort I (low level or Guerin)
- Lefort II (Pyramidal Fracture)
Suprazygomatic
- Lefort III (High level)

25. Fracture ZMC classification

26. Knight and North’s classification : 1961
 Group I : Undisplaced fractures.
 Group II : Arch fractures.
 Group III : Unrotated body fractures.
 Group IV : Medially rotated body
fractures
 Group V : Laterally rotated body
fractures
 Group VI : Complex fractures.

27. Rowe and Killey (1968)
Type I : No significant displacement
Type II : Fracture of the zygomatic arch

28. • Type III : Rotation around vertical axis
Inward displacement of orbital rim
Outward displacement of orbital rim
Outward Displacement Inward Displacement

29. Type IV : Rotation around longitudinal axis
-Medial displacement of frontal process
-Lateral displacement of frontal process

30. Type V : Displacement of the complex en bloc
-Medial
-Inferior
-lateral (Rare)

31.  Type VI : Displacement of orbitoantral partition
- Inferiorly
- Superiorly

32.  Type VII : Displacement of orbital rim segments
 Type VIII : Complex comminuted fractures

33. Fronto-nasoethmoidal region
• NOE complex fractures involve the medial vertical (nasomaxillary)
buttresses of the facial skeleton

34. • NOE fractures are most commonly classified according to Markowitz BL,
Manson PN, Sargent L, et al (1991)
• Type I
• Type II
• Type III
• These can be unilateral or bilateral injuries.

35. Type I
• In unilateral Markowitz type I fractures, there is a single
large NOE fragment bearing the medial canthal
tendon.
• The nasal bone may also be involved and, in cases of
comminution, may not provide adequate dorsal support
to the nasal bridge.

36. Unilateral Type II
• In unilateral type II fractures, there is often comminution
of the NOE area, but the canthal tendon remains
attached to a fragment of bone, allowing the canthus to
be stabilized with wires or a small plate on the fractured
segment

37. Unilateral Type II + Involvement of the nasal bone
• The nasal bone may also be involved and, in cases of
comminution, may not provide adequate dorsal support
to the nasal bridge.

38. Bilateral type II fracture with nasal bone involvement
• Bone grafting of the nasal dorsum may be
necessary

39. Type III
• In type III fractures, there is often comminution of the NOE area (as
in type II fractures) and a detachment of the medial canthal tendon
from the bone.

40. Type III + Involvement of the nasal bone

41. Bilateral type III fracture with nasal bone involvement

42. Frontal bone fracture classification
• Stanley’s modification of Gonty’s classification :
• Type I : anterior table fracture
• Type II : anterior and posterior table fractures
• Type III :posterior table fracture
• Type IV : through and though frontal sinus fracture

43. Clinical features
CLINICAL FINDINGS IN MIFACIAL FRACTURES
# Types I II III ZM NOE Blow out
SYMPTOMS
Air way obstruction ++/-- -- +/- --
Facial Asymmetry and
crepitus/ Dish deformity
++++++ --
CSF leak -- ++/-- -- +/- +/-
Diploplia -- ++/--
Ecchymosis
Buccal vestibule + -- + -- --
Periorbital -- ++
Subconjunctival -- ++
Enophthalmos -- ++/--
Epistaxis +/- ++/-- +/-
ZM dysjunction -- + -- + +/- --

44. CLINICAL FINDINGS IN MIFACIAL FRACTURES
# Types I II III ZM NOE Blow out
SYMPTOMS
FZ dysjunction -- ++ +/- -- --
Facial Ht. increase,
Post. Gagging.
+/- ++ ---
Trismus/ Malocclusion /
Ant open bite.
+++ +/- ---
Medial canthus deformity -- ++/-- -- +/- --
Teeth mobility +++ ---
Septal deformity ++/-- -- +/- --
Ant. cheek
paraesthesia
-- +++ -- +/-
Pupil Ht. unequal -- ++/-- -- +/-
EOM dysfunction -- +++/---

45. Anatomic considerations
• Facial Buttresses
• Maintain projection and protection of the airway.
• House and protect key functional units.
• Provide anchor for suspension of muscular
aponeurotic system.

46. • The vertical buttresses include the nasomaxillary,
zygomaticomaxillary, and pterygomaxillary
buttresses.
• The condyle and posterior mandibular ramus
make up another buttress that establishes
posterior facial height.

47. • The horizontal buttresses are also described as
anterior posterior buttresses.
• These include the frontal, zygomatic, maxillary, and
mandibular buttresses

48. Initial evaluation
• Initial examination should focus on stabilizing the patient by
securing the airway if necessary, management of bleeding and
prompt consultation with other specialists.

49. Airway

50. Bleeding
• Common sites of troublesome bleeding include tongue, scalp,
and mid face/nose.
• Arterial bleeders need to be identified and controlled.
• Temporary tacking sutures can be placed to aid with
hemostasis, especially in large scalp wounds.
• Nasal passages may need to be packed with bilateral Foley
catheters and intranasal gauze to tamponade the area of
hemorrhage.

51. Specialist consultation

52. Reconstruction
• Principles
• Prioritize function and preservation of brain, vision, hearing
• Open mandible fractures should be stabilized as soon as
possible for osseous health
• Support framework until final reconstruction can take place
• Preserve integrity and health of overlying soft tissue and
subunits
• Neurovascular and ductal elements
• Cranial nerves
• Lacrimal system
• Fracture planning
• Grafting (augment support system)

53. Key Landmarks
• Known landmarks and anatomy can be used to reconstruct
more precisely those areas that have been damaged.
• Dental arches, mandible, sphenozygomatic suture, maxillary
buttress, and intercanthal region.
• Dental Arches
• When one or both of the dental arches are intact, they can be
used as guides.

54. • The Mandible
• Anatomic reduction at the symphysis and/or body
can be achieved with an extraoral exposure of the
fracture.
• When bilateral sub condylar fractures are present,
they must be treated to establish the posterior
facial height and facial width.
• The mandibular condyle can be reconstituted to
the mandibular ramus to help establish facial
height and width.

55. • Sphenozygomatic Suture
• key landmark for both the reduction and
the fixation of the zygomaticomaxillary
complex.
• usually exposed along the internal surface
of the lateral orbital wall.
• Once reduced, a small plate can be placed
across this fracture for fixation.

56. • Intercanthal Region
• The intercanthal region may also be
used to reestablish midfacial width
because the intercanthal distance is
fairly constant in the adult facial
skeleton.(30–31 mm)

57. Imaging
• Plain film radiography and linear tomography were the gold
standard until the advent of computed tomography (CT).
• CT allows the clinicians to determine not only the location of
fractures but also the degree and direction of displaced
segments.
• With current CT technology, the maxillofacial trauma surgeon
can evaluate the fracture pattern by viewing individual cuts or
the three-dimensional reconstructions.

58. SEQUENCE OF TREATMENT
• Airway Management
• Establishing occlusal integrity and
stability provides for some initial
horizontal and vertical relationship from
which other related units may be
established.

59. Fracture Management
• Sequence A: Bottom-Up and Inside-Out
• Repair of palatal fracture
• Maxillomandibular fixation
• Repair of condyle fracture
• Repair of mandibular fractures
(body/symphysis/ramus)
• Repair of zygomaticomaxillary complex
fracture (including arches)
• Repair of frontal sinus fracture
• Repair of naso-orbitoethmoid complex fracture
• Repair of maxilla

60. • Sequence B: Top-Down and Outside-In
• Repair of frontal sinus fracture
• Repair of bilateral zygomaticomaxillary
complex (including arch) fracture
• Repair of naso-orbitoethmoid fracture
• Repair of Le Fort fracture (including
midpalatal split)
• Maxillomandibular fixation
• Repair of bilateral subcondylar fractures
• Repair of mandibular fracture
(symphysis/body/ramus)

61. • This latter approach uses a stable fronto-orbital frame from
which to proceed inferiorly and outside-in.
• The main argument in favor of a “top-down” approach is the
ability to avoid opening and fixating condylar fractures.
• Working from a “known” or stable area (less displacement or
comminution) and proceeding to an “unknown” area can make
proper reduction more manageable and achievable.

62. Hard tissue considerations
• Superoposteriorly rotated and impacted mid-facial fractures can be
difficult to mobilize, which requires firm and controlled disimpaction
with forceps.
• During disimpaction, profuse bleeding can be encountered by the
surgeon from posterior areas of the internal maxillary artery
distribution and venous plexus.
• Inadequate reduction and fixation can lead to problems with facial
width, height, and projection.

65. • Functional cavities also need to be addressed and restored to
their preoperative volume.
• Orbital volume, if not properly restored early in reconstructive
management, can be a very difficult problem to manage after
healing.
• Volumetric analysis through computed tomographic (CT)
planning is possible if there is unilateral injury.
• Bilateral volume loss will necessitate critical focus on orbital
frame reduction and reestablishing the superolateral orbital
walls if involved.

66. • The oral cavity is often neglected as a functional unit in
panfacial injury.
• Both vertical loss of the posterior mandible and maxilla and
anterior under projection of the maxillary-mandibular complex
can adversely impact speech and swallowing.
• Significant or avulsive injuries contribute to hurdles in achieving
pretraumatic speech and swallowing mechanisms, in turn
decreasing patient quality of life.

67. • Nasal passage patency depends on properly positioned vertical
and horizontal supports at the nasofrontal unit and septal
stability.
• Dorsal grafting is necessary to preserve projection and
attendant patency
• If the septum is displaced, then rigid stents should be placed for
2 weeks to provide vertical support, prevent hematoma
formation, and provide support to shredded mucosa.

68. Bone Grafting and Soft Tissue
Resuspension
• Two procedures have improved outcomes in the management
of panfacial trauma: primary bone grafting and resuspension of
the soft tissue after extensive exposure of the facial skeleton.
• Common areas that may require primary bone grafting include
the frontal bone, nasal dorsum, orbital floor, medial orbital wall,
and zygomaticomaxillary buttress.

69. • There are many potential sources of bone for a graft, but
calvarial bone may be the best.
• These grafts have been shown to resist resorption better than
endochondral bone.
• Rigid fixation of these grafts has been shown to decrease
resorption.

70. • The soft tissue envelope must be given adequate attention to
avoid disappointing results.
• If possible, limiting exposure and extent of dissection to
fractured elements can help prevent some soft tissue sagging.
• Re approximation of periosteum and resuspension of the
musculo-aponeurotic envelope are critical to restoration of form
and function after injury.

71. • Its reattachment is usually accomplished by drilling holes in key
locations to fix the periosteum to the bone.
• Suspension of the lower eyelid with canthopexy and the malar
fat pad is important to avoid lid laxity/incompetence and cheek
sagging.
• Areas where periosteal reattachment should be obtained
include the malar eminence and infraorbital rim, temporal fascia
over the zygomatic arch, medial and lateral canthi, and mentalis
muscle.

72. Soft tissue augmentation
• Necessary to lend support to either extensively stripped or avulsed soft
tissue, or where loss of bulk may be anticipated.
• There are several tissue sources available to assist in contour and support
measures.
• Acellular dermis
• Fascia
• Fat

73. • Acellular dermis-available in various thicknesses and sizes and
affords a good way to provide Temporary dermal coverage or
augment the subcutaneous tissues in the event of tissue loss.
• Achieve a more normal postoperative contour and avoid
excessive scarring of the overlying skin to deeper tissues or
bone.
• Placement at the time of injury provides a key support to these
tissues and may avoid late cicatrization and accompanying
dysfunction.

74. • Fascial strips harvested from the temporalis or lateral thigh can
also be used as suspensory ligament bolsters in the oral
commissure or malar area in the event of avulsion or shredding
of the attendant musculo-aponeurosis.
• Harvested fat can be placed as an injectable or dermal-fat graft
to achieve facial form and contour where tissue has been lost,
particularly over the malar eminence.

75. • These free grafts cannot be expected to replace missing hard
tissue and they should not be placed over bone with
questionable viability as such osseous tissue requires an
established viable tissue envelope to ensure survival.
• For intraoral defects the buccal fat graft is an excellent local
source for augmentation and protection of exposed palatal bone
or defects.

76. Conclusions
• The management of panfacial fractures is extremely complex
because of the association of concomitant injuries, increased
patient morbidity, and functional impairment often
accompanying these injuries.
• Management must focus on prompt and thorough evaluation,
prioritizing treatment (often staged) to preserve function and
tissue viability, and providing for support to fractures if reduction
and fixation cannot be achieved quickly.

77. • A systematic approach to planning and carrying out that plan for
facial fracture reconstruction will involve focus on reestablishing
proper occlusal, vertical and horizontal relationships in the facial
frame, as well as restoration of orbital, oral, and nasal
cavities/volume.
• Last, detail and time given to soft tissue resuspension and
augmentation will help achieve a lasting and satisfying result
after a devastating facial injury.

78. Thank you