CHAPTER 28
Management of Panfacial Fractures
Patrick J. Louis, DDS, MD
Management of patients with multiple
displaced and comminuted fractures can
be extremely challenging not only for
those who are inexperienced but also for
experienced surgeons. Improper diagno-
sis, treatment planning, and sequencing
produce inadequate results and can
lengthen procedure time. However, with
the availability of detailed imaging,1–3
ridged fixation,4–6 bone grafting tech-
niques,7–9 and proper sequencing,4,10,11
outcomes can be optimized.
All facets of facial form and function
are important, and one should strive to pre-
serve them. The importance of proper
occlusion cannot be underestimated since
acute changes in the way teeth come togeth-
er can be readily detected by the individ-
ual.12 Such alterations can result in myofas-
cial or temporomandibular joint pain.13
Reestablishing the patency of the nasal cav-
ity is important in the prevention of nasal
obstruction and potential problems such as
sinusitis and obstructive sleep apnea.14,15 It
is also required to establish the proper qual-
ity of speech.16 Small changes in orbital vol-
ume can result in enophthalmos and/or
diplopia.17,18 The reestablishment of facial
height, width, and projection is important
for the prevention of facial deformities and
for the psychological and social well-being
of the individual.19–21 No one of these fac-
tors can be considered more important
than the other; together they constitute the
face and its associated functions.
In this chapter, discussion is presented
on some of the historic perspectives, etiol-
ogy, anatomic considerations, imaging,
bone grafting, soft tissue resuspension,
sequencing of treatment, and complica-
tions as they relate to the management of
panfacial fractures.
Historic Perspective
Panfacial fractures are defined as those
involving the upper, middle, and lower
thirds of the face.4 These complex injuries
are fractures that involve the frontal bones,
zygomaticomaxillary complex, naso-
orbitoethmoid region, maxilla, and
mandible. Complex facial injuries such as
these are generally the result of high-
velocity trauma.22 Prior to the advent of
rigid fixation techniques,23–25 these frac-
tures were treated with wire fixation and
head frames.26–28 With these techniques it
was difficult to establish and maintain the
three-dimensional stability of the facial
skeleton.
There have been several important
advances in the management of maxillo-
facial trauma that have resulted in
improved outcomes. These include the
development of high-resolution comput-
ed tomography, rigid fixation techniques,
soft tissue resuspension, and primary
bone grafting. All of these have made a
significant impact on the diagnosis and
treatment of panfacial injuries; each is
discussed later in this chapter.
Etiology
Panfacial fractures result from motor vehi-
cle collisions, assault, sports-related acci-
dents, industrial accidents, and gunshot
wounds.22,29–32 Since gunshot wounds are
addressed in Chapter 26, and because
there is usually associated soft tissue dam-
age causing them to generally require dif-
ferent principles of management, they are
not discussed in this chapter.
Anatomic Considerations
Facial Buttresses
Many authors have described the buttresses
of the face both in vertical and horizontal
planes.10,32–34 The vertical buttresses include
the nasomaxillary, zygomaticomaxillary, and
pterygomaxillary buttresses (Figure 28-1).
The nasomaxillary buttress includes the
maxillary process of the frontal bone and
the frontal process of the maxilla, extending
lateral to the piriform rim. The zygomati-
comaxillary buttress is composed of the
zygomatic process of the frontal bone, lat-
eral orbital rim, lateral zygomatic body, and
zygomatic process of the maxilla. The
pterygomaxillary buttress includes the
pterygoid plates of the sphenoid and maxil-
lary tuberosities. Usually the nasomaxillary
and zygomaticomaxillary buttresses are
reconstructed, but the pterygomaxillary
buttress is not because of inaccessibility.
The condyle and posterior mandibular
548 Part 4: Maxillofacial Trauma
Nasomaxillary
Zygomaticomaxillary
Pterygomaxillary
Posterior mandibular
ramus/condyle
FIGURE 28-1 Vertical buttresses of the face.
ramus make up yet another buttress estab-
lishing posterior facial height.
The horizontal buttresses are also
described as anterior posterior buttresses.10
These include the frontal, zygomatic,
maxillary, and mandibular buttresses
(Figure 28-2). The frontal buttress is
composed of the supraorbital rims and
the glabellar region. The zygomatic but-
tress consists of the zygomatic arch, zygo-
matic body, and infraorbital rim. The
maxillary and mandibular buttresses are
composed of the basal bone of the maxil-
la and mandible arches.
None of these buttresses exists in a
vacuum. Together they give the facial
skeleton its structural integrity. The bone
is generally thicker over these described
areas to neutralize the forces of mastica-
tion or impact. With the proper reduction
of these buttresses, we are able to recon-
struct the height, width, and projection of
the face.
Frontal
Zygomatic
Maxillary
Mandibular
FIGURE 28-2 The horizontal buttresses of the face.
Key Landmarks
When there are multiple facial fractures
involving the upper, middle, and lower
face, reconstruction should be approached
as a puzzle. Known landmarks and anato-
my can be used to reconstruct more pre-
cisely those areas that have been damaged.
Some key landmarks that may help in
establishing the proper positioning of the
facial skeleton include the dental arches,
mandible, sphenozygomatic suture, maxil-
lary buttress, and intercanthal region.
Dental Arches
When one or both of the dental arches are
intact, they can be used as guides. For
example, if the patient has suffered a Le
Fort fracture but no midpalatal split, the
maxilla, as an intact arch, can be used to
set the mandibular arch and establish
proper width. Particularly problematic is
the situation in which there is a mid-
palatal split and the mandible is also frac-
tured along the tooth-bearing region,
with associated condyle fractures. This
can easily lead to widening of the entire
facial complex if these segments are not
properly reduced. One approach to this
problem is to reestablish the maxillary
width by exposing the palatal fracture,
then reducing and fixating the region
(Figure 28-3).34–37 This approach works
well if there is a solitary midpalatal frac-
ture without comminution or avulsion. A
second approach is to obtain impressions
for fabrication of dental models. Simulat-
ed surgery can then be performed on the
upper and lower casts and a surgical splint
fabricated (Figure 28-4).38,39 This is by no
means a foolproof method when both the
upper and lower arches are fractured. The
more severe the injury (ie, multiple seg-
ments), the more difficult it is to establish
a preinjury occlusion. If the patient has
dental models of his preinjury occlusion

FIGURE 28-3 Reduction and fixation of a
palatal fracture using a miniplate.
from previous orthodontic or prosthetic
rehabilitation, these can provide invalu-
able clues to establishing the proper arch
form. A third option is to reconstruct the
mandible since this is generally a robust
bone that can undergo anatomic reduc-
tion if attention is paid to detail.
The Mandible
Anatomic reduction at the symphysis
and/or body can be achieved with an
extraoral exposure of the fracture. Such
exposure allows for direct visualization
A B
FIGURE 28-4 Dental models from one patient: postorthodontic models (A), post-trauma models (B).
Model surgery has been performed on these casts using the postorthodontic models as a guide (C).
Management of Panfacial Fractures 549
of the inferior border and, to a lesser orbital roof and superior lateral orbit are
degree, the lingual cortex. The reduction intact, this suture can be an important
of both the buccal and lingual cortical landmark for the proper positioning of the
surfaces prior to fixation yields better zygoma and zygomatic arch. The sphe-
results (Figure 28-5).40,41 When bilateral nozygomatic suture is usually exposed
subcondylar fractures are present, they along the internal surface of the lateral
must be treated to establish the posterior orbital wall (Figure 28-6).
facial height and facial width. When Once reduced, a small plate is placed
bilateral subcondylar fractures are pre- across this fracture for fixation. Since the
sent and there is an associated fracture
along the symphysis and/or body region,
the mandible may undergo splaying,
with a resultant increase in facial width.
The lateral pterygoid muscle attachment
at the pterygoid fovea, as well as the lat-
eral capsular ligament of the temporo-
mandibular joint, acts to prevent
extremes of movement laterally. The
mandibular condyle can be reconstituted
to the mandibular ramus to help estab- A
lish facial height and width.
Sphenozygomatic Suture
The sphenozygomatic suture, along the
internal surface of the lateral orbital wall,
has been shown in cadaver studies to be a
key landmark for both the reduction and
fixation of the zygomaticomaxillary com-
plex.42–44 If other aspects of the facial
skeleton are ignored, use of this suture
alone can result in errors; however, if the B
FIGURE 28-5 Nonreduced mandibular fracture
involving the symphysis and condylar process
(A). Poorly reduced mandibular symphysis frac-
ture with nonreduced lingual cortex and lateral
C displacement of the mandibular angles (B).
Well-reduced mandibular symphysis and condy-
lar process fractures (C). Note the approxima-
tion of the lingual cortex in the symphysis region.
550 Part 4: Maxillofacial Trauma
FIGURE 28-6 Reduction and fixation of the
sphenozygomatic suture.
orbital roof and superior lateral orbit are
rarely fractured, they are usually accurate
landmarks. Likewise, the zygomatic but-
tress is important in establishing the
proper position of the zygoma and/or
maxilla. Once the zygoma is in the prop-
er place, the location of the maxilla can
be verified. This broad area of surface
contact aids in the reduction and fixation
process. If there is significant bone loss in
this region, consideration should be
given to primary grafting to reestablish
this buttress.
Intercanthal Region
The intercanthal region may also be used to
reestablish midfacial width since the inter-
canthal distance is fairly constant in the
adult facial skeleton.45 Restoration of the
proper intercanthal distance via reduction
of the naso-orbitoethmoid complex can
help to determine facial width (Figure 28-
7).10 This depends mainly on the fracture
type. If there is minimal or no comminu-
tion in the region, proper reduction can aid
in reestablishment of facial form. Unfortu-
nately, many times this area is severely com-
minuted and is of little help. Establishing
the proper intercanthal distance through
measurement is usually performed in cases
with severe comminution.
A
B
FIGURE 28-7 A, Clinical photograph of patient
who has a naso-orbitoethmoid fracture with an
intercanthal distance of 43 mm. B, Intraopera-
tive photograph showing exposure of the naso-
orbitoethmoid fracture.
Imaging
Imaging of the facial skeleton has gone
through a gradual evolution in the area of
facial trauma. Plain film radiography and
A B
FIGURE 28-8 Computed tomography showing midfacial fractures and a left condylar head fracture
on the axial view (A), and a left condylar head fracture on the coronal view (B).
linear tomography were the gold standard
until the advent of computed tomography
(CT).46–49 CT has improved our ability to
image the facial skeleton and obtain details
not possible with plain films (Figure 28-8).1
It allows the clinicians to determine not only
the location of fractures but also the degree
and direction of displaced segments.2,3 Since
the introduction of CT, it has undergone an
evolution both in the quality of the images
and its application. In a previous article
authors reported on “sophisticated CT,” in
which 5 mm cuts through the facial skeleton
were presented.2 It is now a routine practice
at the University of Alabama at Birmingham
to obtain 0.75 mm axial cuts with coronal
reconstructions. This allows for three-
dimensional reconstruction (Figure 28-9), if
needed, and decreases the number of repeat
scans.50,51 The scans are loaded onto the hos-
pital information system and can be viewed
on computers throughout the medical cen-
ter and at remote locations. This decreases
costs by avoiding the production of multiple
hard copies, and it improves efficiency.
With current CT technology, the max-
illofacial trauma surgeon can evaluate the
fracture pattern by viewing individual cuts
or the three-dimensional reconstructions.3
This allows the surgeon to view necessary

A B
FIGURE 28-9 A and B, Three-dimensional computed tomography images of patient with extensive
midface injuries. Note the detail and quality of the images.
details or the overall injury pattern. By
manipulating the image windows on a
monitor, the surgeon can view hard and
soft tissue details. Soft tissue details that
can be viewed on CT are not readily
apparent on plain films. These include
intracranial injuries, injuries to the globe,
presence and location of foreign bodies,
extraocular muscle entrapment, soft tissue
avulsion, displaced teeth, and the airway. If
a cervical spine injury is suspected, it may
be imaged at the time of cranial and max-
illofacial imaging.
The combination of physical exami-
nation and current CT imaging allows a
clear treatment plan to be generated. This
helps greatly with sequencing at the time
of surgery.
Surgical Approaches
Approaches to the facial skeleton in panfa-
cial trauma should permit wide exposure
of the fracture to allow for anatomic
reduction. The location and extent of
exposure are dependent on fracture sever-
ity and combination. The following
describes which fractures can be accessed
through the various surgical approaches
(Figure 28-10):
• Bicoronal flap procedure: frontal
sinus, naso-orbitoethmoid (superior
aspect), medial canthal tendon, supra-
orbital rim, orbital roof, superior
aspect of the medial and lateral orbital
wall, zygomatic arch, and mandibular
condyle (with preauricular extension)
• Subciliary and transconjunctival inci-
sion with lateral canthotomy: infraor-
bital rim, medial and lateral orbital
wall, and orbital floor. The transcon-
junctival incision with lateral cantho-
tomy does allow access to the fron-
tozygomatic suture. This requires
detachment of the lateral canthal ten-
don and incision through the orbicu-
laris oculi muscle and periosteum
deep to the lateral periorbital skin.
The subciliary approach may allow
better access to the lateral nasal region
• Upper eyelid crease incision: superior
and lateral regions of the orbit. It is gen-
erally used to expose the frontozygo-
matic suture. This incision is not need-
ed when the bicoronal incision is used
• Perinasal incisions: naso-orbitoeth-
moid region, medial canthal tendon,
and nasolacrimal sac. These incisions
are generally avoided because of the
Management of Panfacial Fractures 551
potential for significant scarring. This
incision is not needed when the
bicoronal incision is used
• Maxillary vestibular incision: maxilla
and zygomaticomaxillary buttress
• Mandibular vestibular incision:
mandible from the ramus to the sym-
physis. This approach is not usually rec-
ommended for comminuted fractures
• Cervical incisions: mandible, except for
when there is a high condylar neck
fracture. The approach is generally
indicated when anatomic reduction is
crucial. It allows the surgeon to visual-
ize the reduction of the lingual cortex.
It is also indicated for comminuted and
complicated fractures such as a fracture
of the atrophic edentulous mandible
Bone Grafting and
Soft Tissue Resuspension
Two procedures have improved outcomes
in the management of panfacial trauma:
a
b
c
d
e
f
g
h
FIGURE 28-10 Surgical approaches to the facial skeleton:
bicoronal with preauricular extension (a), paranasal (b),
superior tarsal crease (c), subciliary (d), transconjuncti-
val with lateral canthotomy (e), maxillary vestibule (f),
mandibular vestibule (g), cervical crease (h).
552 Part 4: Maxillofacial Trauma
primary bone grafting and resuspension of
the soft tissue after extensive exposure of
the facial skeleton.7–9 As previously dis-
cussed, the facial buttresses are areas that
can serve as guides in the reduction of the
facial skeleton and provide stabilization of
fractures. With high-velocity trauma, com-
minution and loss of bony segments can
occur in the buttress and “nonbuttress”
areas of the face. When these defects are
significant, the surgeon may consider the
use of bone grafting to prevent soft tissue
collapse and to allow for structural support
of the facial skeleton. Previous articles have
reported on primary bone grafting with
few complications.7–9 Even when the bone
graft becomes exposed, secondary wound
healing generally occurs. Common areas
that may require primary bone grafting
include the frontal bone, nasal dorsum,
orbital floor, medial orbital wall, and zygo-
maticomaxillary buttress.
There are many potential sources of
bone for a graft, but calvarial bone may be
the best. Access is often achieved through
a bicoronal flap that has already been cre-
ated during the management of the frac-
tures. These grafts have been shown to
resist resorption better than endochon-
dral bone.8 Rigid fixation of these grafts
has been shown to decrease resorption
(Figure 28-11).8
Soft tissue resuspension after surgical
access to facial fractures is important for
FIGURE 28-11 Primary bone graft rigidly
fixed into position to reconstruct the anterior
maxillary sinus wall including the nasomaxil-
lary and zygomaticomaxillary buttress. (Cour-
tesy of James Koehler, DDS, MD.)
long-term facial esthetics.42,52,53 Resuspen-
sion may be especially beneficial in the
midface region. For repair of midface frac-
tures, the region is usually exposed transo-
rally and from a periorbital approach.52
The soft tissue attachment over the mid-
face is customarily completely stripped.
This frequently results in sagging of the
soft tissue, with reattachment at a more
inferior position. Manson and colleagues
stated that there are two steps to placing
the soft tissue back into proper position
after exposure of the facial skeleton: refixa-
tion of the periosteum or fascia to the
skeleton, and closure of the periosteum,
muscle fascia, and skin where incisions
have been made.42 The periosteum is
inflexible and limits soft tissue lengthening
and migration. Its reattachment is usually
accomplished by drilling holes in key loca-
tions to fix the periosteum to the bone.
Areas where periosteal closure should be
obtained include the frontozygomatic
suture, infraorbital rim, deep temporal fas-
cia, and muscular layers of maxillary and
mandibular incisions.32,42,52,54 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.42
Sequence of Treatment
Airway Management
How to maintain the airway is a crucial
decision in the management of panfacial
fractures. There are several options that are
dictated by the fracture pattern and extent
of other injuries. When there are extensive
head injuries and prolonged intubation is
anticipated, tracheostomy should be con-
sidered.55–57 Likewise, tracheostomy is an
appropriate option to facilitate the man-
agement of multiple facial fractures.10,56,57
In many cases there are extensive injuries
to the naso-orbitoethmoid region, making
nasal intubation difficult and haz-
ardous.58,59 With nasal intubation, access to
the frontal sinus and naso-orbitoethmoid
region is hindered.
Oral intubation may be an option when
maxillomandibular fixation is either not
possible or not indicated. When prolonged
intubation is not anticipated, options
include submental intubation60,61 or passing
the tube behind the dentition, if space per-
mits. If an extraoral approach is indicated to
manage a mandibular body/angle fracture
or a symphysis fracture, submental intuba-
tion may hinder access.
Fracture Management
Much has been written about the proper
sequencing of treatment for panfacial frac-
tures.10,28,42,52,62 Sequences such as “bottom
up and inside out” or “top down and out-
side in” have been used to describe two of
the classic approaches for the management
of panfacial fractures. To my knowledge
there have been no randomized studies to
ascertain whether one approach is superior
to the other. The bottom up and inside out
approach predates the use of rigid fixation
but it is still a valid approach. It establishes
the mandible as a foundation for setting the
rest of the face and includes open reduction
and internal fixation of subcondylar frac-
tures, as well as the remainder of the
mandible. The occlusion is set by placing
the patient in maxillomandibular fixation;
then, the maxilla should be in the proper
position. Realignment of the zygomatic
buttresses follows in this sequence; howev-
er, fixation at this point may lead to inaccu-
racies in upper midface position. Instead, a
break in the sequence is usually preferred
here. The zygomaticomaxillary complex is
reduced and fixated first. This allows for a
more accurate repositioning of the upper
midface before fixation at the zygomatic
buttress. The maxilla is now fixated along
the zygomaticomaxillary buttress. Last, the
naso-orbitoethmoid fracture is reduced
and stabilized (Figure 28-12).62
The opposite approach, top down and
outside in, starts at the zygomatic region.
The sphenozygomatic suture is reduced
 Management of Panfacial Fractures 553

A B C

D E F

FIGURE 28-12 Bottom up and inside out surgical

approach. A and B, Sequencing of panfacial frac-
tures can begin with maxillomandibular fixation.
This is followed by reduction and fixation of the
subcondylar fractures followed by the symphysis,
body, or angle fracture. C and D, The zygomas are
reduced and fixated next using the sphenozygomat-
ic suture, zygomatic arch, and zygomaticomaxillary
sutures as guides. E and F, The maxilla can now be
stabilized in along the zygomaticomaxillary but-
tress. G and H, The naso-orbitoethmoid fracture
can now be reduced and fixated at the nasofrontal
and frontomaxillary sutures and the infraorbital
and piriform rims.

G H
554 Part 4: Maxillofacial Trauma

A B C

D E F

FIGURE 28-13 Top down and outside in surgical

approach. A and B, Sequencing of panfacial frac-
tures can begin with the zygomas using the sphe-
nozygomatic suture and the zygomatic arches as
guides. C and D, The naso-orbitoethmoid fractures
can be reduced next and fixated at the nasofrontal
suture and maxillofrontal sutures and infraorbital
rim. E and F, The maxilla is reduced and fixated.
Stabilization is achieved at the nasomaxillary and
zygomaticomaxillary buttresses. G and H, The
mandible is reduced last in this sequence. This is
accomplished with the use of maxillomandibular
fixation followed by reduction and fixation of the
mandibular fractures.

G H

and fixated inside the orbit. The zygomatic
arch is reduced and plated. If the arches are
not properly reduced, underprojection of
the midface can result. The alignment of
the arch can be verified by the proper posi-
tion of the sphenozygomatic suture. From
this point the zygomas can be further posi-
tioned and fixated at the frontozygomatic
suture. The naso-orbitoethmoid complex is
then positioned to the supraorbital rims,
infraorbital rims, and maxillary process of
the frontal bones. The maxilla is addressed
next using the position of the zygomatico-
maxillary buttress and piriform rim as a
guide. Maxillomandibular fixation can then
be established (Figure 28-13).52 Reduction
and fixation of the mandibular condyle and
the symphysis/body/angle fractures are
then performed.
Some surgeons feel that there is a sig-
nificant advantage to the top down and
outside in approach because open treat-
ment of the condyles may not be neces-
sary. The patient is treated with varying
periods of maxillomandibular fixation,
which may be a valid approach in the case
of comminuted intracapsular fractures.
Although this is a viable option in some
cases, there are two potential complica-
tions. One is an unrecognized rotation of
the body or ramus of the mandible, result-
ing in widening. A second complication is
temporomandibular joint ankylosis
caused by the inability to begin early phys-
ical therapy. One author reviewed closed
treatment of mandibular condyle fractures
and showed compromised results.63 Early
function of patients with condylar head
fractures is usually indicated, along with
guiding elastics to maintain the range of
motion of the temporomandibular joint.
Neither one of these techniques will
achieve optimal results in every situation.
Instead, an approach that goes from
known to unknown is certainly more
accurate. For example, if there is a signifi-
cant calvarial injury, it may be difficult to
start from the cranium and proceed cau-
dally. In this case, a sequence that starts
caudally and proceeds cranially may
achieve more optimal results, allowing the
surgeon to reconstruct the damaged cra-
nial portion last. On the other hand, if
there is significant comminution of the
mandible or if key segments are missing, it
may be more appropriate to start cranially
and proceed caudally. Thus, the maxillofa-
cial trauma surgeon must be comfortable
with both approaches and use known
landmarks to achieve optimal results.
In Tables 28-1 and 28-2, two common
sequences of management of facial frac-
tures are illustrated. Other sequences
exist, but they are variations of these two
major approaches.
Complications
There are many complications that are
associated with various fractures; these are
discussed elsewhere in the text, with refer-
ence to the specific fracture type. However,
a significant complication associated with
panfacial fractures that I will discuss here is
widening of the facial complex. This occurs
when the surgeon fails to properly reduce
key areas that guide in establishing facial
width.42 If the first area approached is fix-
ated in an improper location, subsequent
fragments will be reduced and fixed in an
improper spatial arrangement, resulting in
a series of errors and, usually, a widened
facial complex. To prevent this, the surgeon
must use stable segments, known land-
marks, and anatomic reduction in the
management of panfacial fractures.
If the complication does occur, the
surgeon must assess the patient and deter-
mine the severity and location of the prob-
lem. This is done through physical exami-
nation and CT imaging (Figure 28-14). In
severe cases three-dimensional computed
tomographic reconstruction of the entire
facial skeleton can be obtained and, if indi-
cated, a three-dimensional stereolitho-
graphic model can be made.64,65 The model
allows the surgeon to identify and recreate
the fractures during model surgery. The
fracture may be reduced anatomically and
Management of Panfacial Fractures 555
stabilized with plates, which can then be
sterilized and used at the time of surgery.
This technique and the use of proper land-
marks can aid in the proper reduction and
fixation of the fractures.
Conclusions
The management of panfacial fractures is
extremely complex. There are, however,
many technologic advances that can aid the
surgeon in the proper management of these
fractures. The most important of these
advancements is imaging. With the advent
of high-resolution scanners, the surgeon
has a more accurate picture of the fracture
Table 28-1 Sequence A: Bottom Up and
Inside Out*
1. Tracheostomy
2. Repair of palatal fracture
3. Maxillomandibular fixation
4. Repair of condyle fracture
5. Repair of mandibular fractures
(body/symphysis/ramus)
6. Repair of zygomaticomaxillary
complex fracture (including arches)
7. Repair of frontal sinus fracture
8. Repair of naso-orbitoethmoid complex
fracture
9. Repair of maxilla
*See Figure 28-12.
Table 28-2 Sequence B: Top Down and
Outside In*
1. Tracheostomy
2. Repair of frontal sinus fracture
3. Repair of bilateral zygomati-
comaxillary complex (including arch)
fracture
4. Repair of naso-orbitoethmoid fracture
5. Repair of Le Fort fracture (including
midpalatal split)
6. Maxillomandibular fixation
7. Repair of bilateral subcondylar
fractures
8. Repair of mandibular fracture
(symphysis/body/ramus)
*See Figure 28-13.
556 Part 4: Maxillofacial Trauma

D E F

G H

FIGURE 28-14 A and B, Twenty-one-year-old male who fell from a height of two stories. Facial fractures included the frontal sinus, naso-orbitoethmoid,
bilateral zygomaticomaxillary complex, Le Fort I with midpalatal split and avulsion of tooth no. 9, mandibular symphysis, and bilateral intracapsular
condyle fractures. In this photograph it is evident that the patient has significant facial widening owing to a failure to establish proper facial width. He also
has bilateral bony ankylosis of the condyles secondary to a closed reduction of the condyle fractures. C and D, Three-dimensional stereolithographic mod-
els generated from CT imaging. Note the significant widening of the mandible and midface. E and F, Simulated surgery was performed on this model and
mandibular plates were prebent. Note the significant narrowing of the model. Mandibular condyles are now positioned in the fossae. G and H, Model
surgery was performed on the dental cast, based on the preorthodontic models that were brought in by the family. A surgical splint was fabricated. (CONTINUED
ON NEXT PAGE)
 Management of Panfacial Fractures 557

I J K

L M

FIGURE 28-14 (CONTINUED) I and J, During the surgical management, the old fractures are exposed via a
bicoronal incision with preauricular extension, transconjunctival incisions with lateral canthotomies, a maxil-
lary vestibular incision, and the use of the previous chin scar. The hardware was removed. The previous fractures
were recreated by performing bilateral condylar process osteotomies, a symphysis osteotomy, and a Le Fort I with
left paramidline split. With the aid of the presurgical splint, the patient was placed in maxillomandibular fixa-
tion. The mandible was reconstructed first by reducing and fixating the condyles and with the aid of the prebent
plates, and by reducing and fixating the symphysis. The arrow points to the condylar process osteotomy and fix-
ation plate. K and L, A Le Fort III osteotomy is created to imitate the initial fractures. This portion of the upper
midface is mobilized and advanced. Greenstick fractures of the zygomatic components of the upper midface are
also performed to rotate the posterior aspect medially. Once reduced, these fractures are fixated with miniplates.
N
M, Last, the maxilla is fixated at the piriform rims and the zygomaticomaxillary buttress with miniplates. The
patient is taken out of fixation to verify the occlusion and begin early function. N, Early postoperative result. Note
the decrease in facial width and increase in facial height. Patient also had zygomatic and recontouring nasal aug-
mentation, bone grafting to the orbits, lateral canthopexy, midface resuspension, and genioplasty. (Courtesy of
Dr. Patrick Louis and Dr. John Grant.)

pattern. Once the proper diagnosis is estab-
lished, the surgeon should be able to insti-
tute an appropriate sequence of treatment.
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