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Multiple facial bone fractures usually are consequential to severe injuries secondary to motor vehicle calamities. These complex and panfacial fractures are usually associated with multiple systemic injuries that mandate a multidisciplinary approach to their management. It involves rebuilding the facial architecture and restoring the facial buttresses to reinstate the cosmetics and function. The complex nature of treatment makes them challenging for the surgeon and thus requires an organized approach for efficient reduction. Various sequences such as bottom--up, top-to-bottom, and occlusion first have been commonly used. This case series presents two cases of complex facial fractures and two cases of panfacial fractures. In these cases, occlusion was first achieved by maxillomandibular fixation. The mandible was first reduced and fixed, followed by the maxilla. [ABSTRACT FROM AUTHOR]

Multiple facial bone fractures usually are consequential to severe injuries secondary to motor vehicle calamities. These complex and panfacial fractures are usually associated with multiple systemic injuries that mandate a multidisciplinary approach to their management. It involves rebuilding the facial architecture and restoring the facial buttresses to reinstate the cosmetics and function. The complex nature of treatment makes them challenging for the surgeon and thus requires an organized approach for efficient reduction. Various sequences such as bottom–up, top-to-bottom, and occlusion first have been commonly used. This case series presents two cases of complex facial fractures and two cases of panfacial fractures. In these cases, occlusion was first achieved by maxillomandibular fixation. The mandible was first reduced and fixed, followed by the maxilla.

The aim of this study was to retrospectively investigate the validity of rigid internal fixation of panfacial fractures (PFFs) without postoperative maxillomandibular fixation (MMF) in patients who underwent open reduction and internal fixation (ORIF). The medical records of patients with PFFs who underwent rigid internal fixation without postoperative MMF from April 2015 to November 2021 were retrospectively reviewed. The locations of PFFs were classified by the location affected. All patients except for 2 head-injured patients had regular follow-up examinations including postoperative imaging for over 6 months. There were 25 patients (15 males, 10 females; median age 51.3 years, range 16–89 years); median body mass index (BMI) 22.4 kg/m2, range 17.3–28.2 kg/m2). The most common location of PFFs was orbital bone (80%), with the exception of the maxilla. Mean operating time was 330 min, and mean blood loss was 120 ml. Postoperatively, one patient (4%) had malocclusion and mouth opening limitation, 5 patients (20%) required elastic traction for postoperative occlusal instability, and 2 patients (8%) had suture dehiscence. Three patients (12%) had postoperative soft tissue problems. Malocclusion or limited mouth opening was seen in one patient each (4%), and no patient exhibited facial asymmetry. The overall complication rate was 16%. The majority of patients (13/25) started oral feeding with a solid diet by postoperative day 3. In conclusion, proactively avoiding postoperative MMF for PFFs in which sufficient occlusal and bone stability can be achieved by rigid internal fixation not only avoids the disadvantages of postoperative MMF, but also provides satisfactory outcomes.

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. [ABSTRACT FROM AUTHOR]

Background and Aims: Airway management in anaesthesia for maxillofacial surgical procedures is tricky at times when the nasal/oral routes are contraindicated or are impossible. Tracheostomy as an alternative inherits its own complications. We present a case series of the submandibular route for tracheal intubation as an alternative. Methods: The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period. Results: Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period. Conclusion: In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon′s field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist.

Intubating a patient with panfacial fractures is always a challenge to the anesthesiologist as both the anesthesiologist and the surgeon are essentially competing for the same space. The anesthetic management of a 19-year-old boy who presented with multiple maxillofacial injuries, pneumocephalus, and cerebral edema sustained during a road traffic accident has been described. He was posted for open reduction and internal fixation of the fractures, frontal sinus fracture elevation and basal repair which required access to scalp, mouth and the nose. As all the conventional modalities to secure airway seemed unsuitable, orotracheal intubation was done via submental route. Following intravenous induction the patient was intubated with a cuffed oral flexometallic tracheal tube. This was then modified to the submental route through a submental incision. The surgery proceeded uneventfully and the patient was extubated a day later in the ICU. He made a satisfactory recovery and the submental scar healed without complication or scarring. We briefly review the technique of submental intubation in adults which serves as an excellent alternative to tracheostomy.

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.

Intubating a patient with panfacial fractures is always a challenge to the anaesthesiologist. In a 40-yr-old male patient with left Le Fort′s III fracture with nasal bone and symphysis menti fracture, we successfully carried out oral endotracheal intubation which was then modified to submandibular approach to provide adequate surgical field. Initially oral endotracheal intubation was performed, then an incision was made in the submandibular region through which the endotracheal tube was brought out and maintained as submandibular approach throughout the surgery.

The case report of a 45 years patient that was assisted in the Emergency Intensive Cares Unit of "Saturnino Lora Torres" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba is described, after falling down of an approximate height of 6 meters due to a high energy impact that provoked him fractures in the three thirds of the facial region. He was surgically treated as an emergency by a multidisciplinary team. After several surgical procedures and intubation with mechanical ventilation for 72 hours, he was referred to the Intensive Cares Unit due to his very serious state, where he stayed during 21 days and had a favorable clinical course. [ABSTRACT FROM AUTHOR]

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Background and Aims: Airway management in anaesthesia for maxillofacial surgical procedures is tricky at times when the nasal/oral routes are contraindicated or are impossible. Tracheostomy as an alternative inherits its own complications. We present a case series of the submandibular route for tracheal intubation as an alternative. Methods: The procedure was performed in ten selected adult patients with maxillofacial/mandibular fractures associated with a fracture of skull base or nasal bone. All of them were medically stable with no need of intensive care or mechanical ventilation in post-operative period. Results: Submandibular intubation in all ten patients of panfacial fractures allowed uninterrupted surgical techniques with a secured airway. All patients were reverted to oro-tracheal tube at the end of surgery as immediate maxillomandibular fixation was not necessary. The patients were extubated after recovery from anaesthesia before they left the operating theatre. One patient in the post-operative period had a superficial infection of incision site that responded well to local treatment. No other complications were encountered in the intra-operative or post-operative period. Conclusion: In complex maxillofacial injuries, when oral or nasal intubation hampers surgeon's field of view, submandibular intubation offers an effective alternative to short-term tracheostomy along with small risk potential. There is a need to emphasise its regular application in such cases so that technique can be mastered by both surgeons and anaesthesiologist. [ABSTRACT FROM AUTHOR]

Purpose: To compare the sequence bottom-up inside-out with top-down outside-in, in the treatment of pan facial fractures and to evaluate the outcome of these approaches. Patients and Methods: The data from 11 patients with panfacial fracture are prospectively analysed. Five cases are treated with bottom-up approach and six patients with top-down approach. Results: There were 11 male patients (six in top-down approach and five in bottom-up approach), ranging in age from 24 to 50 years. All injuries were result of RTA (n = 11, 100 %). Final treatment outcome was excellent in 3 (50 %), 1 (16 %) good and 2 (32 %) cases were fair in topdown approach, 3 (60 %) excellent and 2 (40 %) fair in bottom up approach with contingency coefficient value ( P < .632) which was insignificant. There was no significant deviation from the two groups in the final treatment outcome. Conclusion: Within the limitation of low sample size we found that both bottom-up inside-out and top-down outside-in approaches have similar clinical outcomes. Hence it could be suggestive to start fixation of least disrupted (more stable) facial half as a guide for reconstruction of the remaining. Choice of the bottom-up inside-out or top-down outside-in sequence should be according to the pattern of fractures and preference of the surgeon. However, further controlled clinical trials, comparative studies with a larger sample size would be better to evaluate the final clinical outcome of individual techniques. [ABSTRACT FROM AUTHOR]

Blindness associated with mid-facial fractures is rare. Here we present a case of panfacial fracture associated with loss of vision of right eye. The reconstruction of left orbital region posed a challenge, as post surgical vision loss can be a remote complication. Through this case report we highlight our dilemma and describe the different philosophies adopted by other specialties in management. [ABSTRACT FROM AUTHOR]

Introduction: Although the primary management of patients with panfacial fractures has been well discussed in the medical and dental literature, secondary management of those patients who were not treated or were incompletely treated has not been as well addressed. Purpose: The purposes of this paper are to review the basic concepts of panfacial fractures and to address the secondary reconstruction of patients whose primary management was less than ideal. Discussion: In this paper, we present three cases of secondary reconstruction of the maxillofacial skeleton following complicated panfacial fractures. We also discuss the challenges that exist in treatment planning and executing treatment in these complex cases. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Purpose of this retrospective study was to analyse the protocol for treating panfacial fractures at M.S. Ramaiah Group of Hospitals, Bangalore. Patients and methods: Fifteen patients with panfacial fractures were treated at M.S. Ramaiah Group of Hospitals, Bangalore between January 2008 and July 2012. After clinical and radiological examination, patients with fractures of at least three of the four axial segments of facial skeleton: frontal, upper midface, lower midface, mandible, were included. After stabilizing each patient, timing of definitive management was based on neurological condition. Frontal bone and fronto-zygomatic region were fixed in conjunction with dural repair. Objective was to restore function, facial height, width and projection. Our approach to reduce panfacial fractures is “Bottom up, Inside out” and to fix them is “Bottom up, Outside in”. Mandibular fractures were fixed first to obtain a stable platform to reconstruct mid-face after maxillo-mandibular fixation. Then other fractures were fixed: zygomatico-maxillary complex, infra-orbital rims, LeFort I level and palatal split, and naso-orbito complex. Results: Average age of patients was 34.5 years. Etiology of trauma was predominantly automobile accidents. Total of 65 fractures were recorded in 15 patients. Three patients (20%) had frontal sinus fractures (5%), and 14 (93%) had mandibular fractures. All patients had fractures of midface in different combinations. Postoperatively, occlusion was satisfactory. Radiographs were taken to assess adequacy of fracture reduction and fixation. Conclusion: Timing and sequential management of panfacial fractures in conjunction with neurosurgical team, focused on restoration of function and facial form is required for optimal results. [Copyright &y& Elsevier]

Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma. [ABSTRACT FROM AUTHOR]

Despite a paradigm shift in anesthesia and trauma airway management, the craniomaxillofacial fracture (CMF) patients continue to pose a challenge. A prospective study was planned between April 2007 and March 2015 to investigate the safety, efficacy, utility, and complications of anterior submandibular approach for transmylohyoid intubation (TMI) in CMFs using an armored endotracheal tube (ETT). Out of 1,207 maxillofacial trauma cases reported, this study recruited 206 patients (152 males and 54 females) aged between 21 and 60 years. No episode of oxygen desaturation was noted intraoperatively. Mean time to perform TMI was 6 ± 2 minutes. The mean transmylohyoid ETT withdrawal time/disconnection time from ventilator was approximately 1.5 minutes. Accidental partial extubation of ETT was noted in two patients (0.97%), and three patients (1.45%) developed abscess formations at anterior submandibular site which were managed by incision and drainage. The anterior submandibular approach for TMI was successfully used and provided stable airway in all elective CMF surgery cases, where oral or nasal intubations were not indicated/feasible and long-term ventilation support was not required. It permitted simultaneous dental occlusion-guided reduction and fixation of all the facial fractures without interference from the tube during the surgery with unhindered maintenance of the anesthesia and airway. The advantages include easy, swift, efficient, and reliable approach with a small learning curve.

Summary: Intubating a patient with panfacial fractures is always a challenge to the anaesthesiologist. In a 40-yr-old male patient with left Le Fort's III fracture with nasal bone and symphysis menti fracture, we successfully carried out oral endotracheal intubation which was then modified to submandibular approach to provide adequate surgical field. Initially oral endotracheal intubation was performed, then an incision was made in the submandibular region through which the endotracheal tube was brought out and maintained as submandibular approach throughout the surgery.