The simultaneous fractures that involve the upper third of the face, also known as the cranium, the mandible and mid face are known as the panfacial fractures. The treatment of such complex fractures is complicated for obvious reasons. The surgery on this part of the face is a lot more difficult and complex than other parts because of the fact that the maxillofacial region lies close to important features of the face such as the olfaction, respiration, mastication or chewing, visual function or diplopia, deglutition and a very important aspect of aesthetics. If a surgeon is unable to visualize and reduce all the components of a pan facial injury directly and if the fractured bones are not stabilized adequately, the deformity can be persistent.
The term “panfacial” is made up of words “pan” and “facial”. The word pan is of Greek origin which means “of everything” or “all”. Therefore panfacial fracture means that the fracture is present across the complete facial skeleton. Panfacial fractures are caused by high energy and high impact forces. Therefore they are generally caused due to automobile accidents or in the cases of assault. Panfacial fracture may include fractures to the mandible, zygoma, maxilla, orbital and frontal sinus, nasoethmoid etc.
In case of panfacial fractures, there is large no. of combinations of fractures which are possible. Therefore, there is no conclusive definition of panfacial fractures that will include all the permutations of the fractures of the facial skeleton.
A very important point to remember with pan facial fractures is that it is very difficult to follow a pattern for fracture repair in such cases. A broad outline for diagnosis of panfacial fractures may include:-
Panfacial fractures cause significant damage to the soft tissues and bones. Due to the nature of panfacial fractures they are found with other injuries like injuries to brain, airways, cervical spine etc.
In any case of panfacial fractures, the primary concerns of any trauma surgeon are the breathing, airway and circulation.
Panfacial fractures may pose both delayed and immediate risk of obstruction to the airway. The airway may get immediately obstructed due to accumulation of blood, inhalation of tooth fragments and loss of tongue which can occur in conscious and unconscious patients. The patient is checked for intubation and anesthesia may be required. Even if the patient is breathing normally, it is important to keep in mind that the airway may get obstructed later on due to swelling of the tissues. Maintaining the airway may become progressively difficult if the patient falls unconscious due to injury to the brain or alcohol etc. sometimes, therefore, intubation may be done as a preemptive measure. Some of the challenges may also be faced when the repair of pan facial fractures is planned. The panfacial injuries require a broad access to the skeleton along with intermaxillary fixation. The final choice of airway also depends upon, chest injuries, facial injuries etc.
The goal of the treatment of panfacial fractures is the restoration of the facial anatomy in all the three dimensions. One of the major developments in treatment of panfacial fractures is the development of cone beam technology and 3D imaging. With the help of theses diagnostic tools, the injuries can be addressed individually and the diagnostics are a prerequisite for control of the outcome, planning and reduction.
Two options for sequencing the repair of panfacial fractures are:-
Follow up after the treatment
A thorough postoperative radiological documentation of the panfacial fracture should be maintained. Since panfacial fractures are very complicated therefore they take a long time to heal and a patient should closely follow instructions of the surgeon. Even after complete treatment, the patient may still have some type of residual deformity which may call for additional corrective surgery. A lot of skill and expertise is required to restore the pre trauma anatomy and aesthetics of the patient’s face. Thorough knowledge of maxillofacial is a must for any trauma surgeon who is managing a case of panfacial fractures. Once the patient is stabilized, surgical intervention is necessary to reduce and fix the fractures. The patients should be aware that in most cases, once the primary fixation of panfacial fractures is done, a secondary surgery may be required.