DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

RUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCHKOHKA, BHILAI

PRESENTED BY –

DR. SHEETAL KAPSE

1st YEAR, P.G. STUDENT

MODERATORS -DR. SUNIL VYASDR. M. SATISHDR. MANISH PANDITDR. DEEPAK THAKUR

WHY SHOULD WE START FROM MANDIBULAR FRACTURES IN THE TREATMENT OF PANFACIAL FRACTURES?

Yang R, Zhang C, Liu Y, Li Z, Li Z :Why should we start from mandibular fractures in the treatment of panfacial fractures? J Oral Maxillofac Surg. 2012 Jun;70(6):1386-92. doi: 10.1016/j.joms.2011.11.006.

JOURNAL CLUB

Authors

1. Rongtao Yang - PhD, DDS Doctor, State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, China

2. Chi Zhang - PhD, DDS Attending Doctor, State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, China

3.  Yong Liu - MDS, DDS Doctor, State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, China

4. Zhi Li, PhD, DDS Associate Professor, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, China

5. Zubing Li - PhD, DDSProfessor, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, China

Source of data

State Key Laboratory Breeding Base of Basic Science

of Stomatology (Hubei-MOST) & Key Laboratory of Oral

Biomedicine Ministry of Education, School and Hospital

of Stomatology, Wuhan University, China.

Inclusions -

1. Abstract2. Introduction3. Objectives4. Patients & methods5. Statistical analysis6. Results7. Discussion8. Conclusion9. Resources

Abbreviation used

PFFs = panfacial fractures

NOE = naso-orbito-ethmoid complex

TMJ = temporomandibular joint

Abstract

Clinically, the "bottom-up” and “outside-in" sequence is usually applied in the management of panfacial fractures (PFFs). However, findings to prove that a sequence initiated from the mandible is reasonable are not available.

The data from 107 patients with PFFs from 1998 to 2008 were analyzed retrospectively. All cases were treated with the "bottom-up and outside-in" sequence.

The most common sites of mandibular fractures in PFFs were the symphysis and condyle. The most common type of fracture was the isolated linear fracture.

Significant differences between mandibular fractures in PFFs and general mandibular fractures were found. The type distribution in the former was simpler than that in the latter; the severity was also less serious.

Most PFF patients treated with the proposed sequence presented with satisfactory effects.

Introduction Panfacial fractures (PFFs) are defined as fractures that simultaneously

involve the upper, middle & lower face. This type of trauma mainly involves the mandible, maxilla, zygomatic complex, naso-orbito-ethmoid (NOE) region & frontal bone & is often associated with emergencies.

Clinically the traumatic conditions of PFFs are complicated & vary between patients. However a well developed clinical planning & prognostic evaluation has yet to be reached.

Most commonly used approach is – “bottom-up” & “outside-in”

Bottom-up : reduction of fracture from mandible to frontal bone Outside-in : zygomatic complex, maxilla & NOE region.

Andrew C. Smith, Susan E. Barry, Inferior alveolar nerve damage following removal of mandibular third molar teeth. A prospective study using panoramic

radiography. Australian Dental Journal 1997;42:3.

Wenig BL:Otolaryngologic Clinics of North America [1991, 24(1):93-101]

This classic approach can't resolve all possible cases of PFFs.

Inside-out, immobile-mobile & simple- complicated fractures.

Mandibular fracture in PFFs – 1st step of choice……

Merville L. Multiple dislocations of the facial skeleton J Maxillofac Surg. 1974 Dec;2(4):187-200.

Erol, Behçet, Rezzan Tanrikulu, and Belgin Gorgun. "Maxillofacial Fractures. Analysis of demographic distribution and treatment in 2901patients (25-year experience)." Journal of Cranio Maxillo Facial Surgery 32.5 (2004): 308-313.

But WHY ???????The present study was designed to analyze the distribution features of mandibular fractures in PFFs & provide detail data to support the initiation of PFFs treatment from the mandible .

OBJECTIVE

The objective was to describe the distribution of mandibular fractures in PFFs and investigate the basis for initially addressing the mandible when treating PFFs.

Patients and methods

The data from 107 patients with PFFs admitted to the Dept. of Oral & Maxillofacial Surgery , School & Hospital Of Stomatology, Wuhan University (China) From January 1998 To December 2008 were retrospectively analyzed .

The institutional review board of Wuhan university approved the protocol, survey & consent forms used.

INCLUSION CRITERIA

Simultaneous fracture of mandible, maxilla & zygomatic complex with or without fractures in NOE &/or frontal bone.

Patient with alveolar fracture of maxilla or mandible were excluded.

Male : female = 8.7:1 (96 male & 11 female)

Age = 16 – 64 years.

Dongmei He, Yi Zhang, Edward Ellis III:Panfacial Fractures: Analysis of 33 Cases Treated :Journal of Oral and Maxillofacial Surgery, Volume 65, Issue 12, December 2007, Pages 2459-2465

Sawhney CP, Ahuja RB.Faciomaxillary fractures in north India. A statistical analysis and review of management. Br J Oral Maxillofac Surg. 1988 Oct;26(5):430-4.

Fracture Type

Simple fracture Linear fracture or fractures

with minimal or no displacement.

Simultaneously simple fracture of zygomatic complex, NOE & maxilla region.

Complex fracture Comminuted fractures Fractures with displacement Bilateral simple fractures Complex fracture of one of

the below- Zygomatic complex, - NOE - Maxilla region.

Treatments of PFFs

1. Mandibular fracture - open reduction & internal fixation

2. Frontal fracture – coronary incision

3. Zygomatic complex fracture - fixation at sphenozygomatic, zygomatic arch, zygomaticomaxillry & frontozygomatic suture

4. Maxillary fracture

5. NOE fracture – restoration of intercanthal distance & reattachment of medial canthal ligament.

6. Skull & orbital fracture - titanium meshes & autologus bone graft

ORIF according to “bottom-up” & “outside-in”

Therapeutic Evaluation

On the basis of –

1. Face outline – symmetry without need for

additional surgery for correction

2. Occlusion – in pretrauma level without

need for additional surgery

3. Mouth opening - > 35mm & stable and

normal TMJ function

4. Local deformity - no additional surgery

was necessary for secondary local

deformities in orbital & NOE region,

facial nerve injury & local bony defect.

- Analyzed by 2 similarly trained investigators.

Excellent = 4/4

Good = 3/4

Fair = 2/4

Poor = ¼ or 0/4

Statistical analysis

Data collection and statistical analysis were carried out with SPSS 16.0 (SPSS Inc., Chicago, IL) software.  (originally, Statistical Package for the Social Sciences, later modified to read Statistical Product and Service Solutions)

• Total 164 mandibular fractures in 107 patients • 67/107 (62.6 %) = only 1 fracture in mandible• 26/107 (24.3 %) = 2 fractures in mandible• 12/107 (11.2%) = 3 fractures in mandible• 1/107 (0.9 %) = 4 fractures in mandible• 1/107 (0.9 %) = 5 fractures in mandible

RESULTS

• 148/164 (90.2%) = simple fractures

• 16/ 164 (9.8 %) = comminuted fractures

8 in condyle

4 in body

2 in symphysis

2 in ramus

DISTRIBUTION OF TYPE OF MANDIBULAR FRACTURES IN PFFs

51 Condylar fractures

13 – intracapsular (5/13 comminuted fractures)

28 – condylar neck

10 – subcondylar (3/13 comminuted fractures)

Relationship between mandibular fractures & midfacial fractures or frontal fractures in PFFs

No correlation in incidence between mandibular fracture & frontal fractures in PPF’s was observed.

p > .05

Treatment Effect

Follow up duration = 3-24 months

one half of the patients showed certain deficiencies –

18 patients with face outline

7 in occlusion

28 in mouth opening ( 16 – 34 mm)

23 in local deformity

DISCUSSION

Site & type of distribution of the mandibular fractures in PFFs

The relationship between mandibular fractures & the prognosis of PFFs

Compared with representative data of general mandibular fractures in different sample sizes

Site Of Distribution Of The Mandibular Fractures In PFFs

Compared with representative data of general mandibular fractures in different sample sizes

PPFs – high energy attacks to the front of the face

Condylar neck fracture is most common in condylar fracture associate

with PPFs

Subcondylar fracture – in general condylar fracture.

Type Of Distribution Of The Mandibular Fractures In PFFs

Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast Surg 16:105, 1989

The mandible as an isolated bone in the facial region , determines the height of the lower third of the face by the ramus region & the width & proportion by the body region.

The mandible interacts with the maxilla by occlusion & with the skull by temporomandibular joint, which insures the continuity of both the lower third of the face & the whole facial skeleton.

Because of the importance of mandible, the overall treatment difficulties in the midfacial fractures & the basic treatment principles of fractures , the treatment of PPFs must be initiated from mandible.

Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast Surg 16:105, 1989

Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the management of panfacial fractures." British Journal of Oral and Maxillofacial Surgery 38.5 (2000): 472-476.

Any deficiencies in a step would undoubtedly affect the next step in the treatment sequence for PFFs as such the mandible is of great significance in the treatment of PFFs & should be carefully restored.

In case of unusual type of mandibular fractures in PFFs, extra attention should be exerted.

As a part of TMJ, the condyle affects the mouth opening & the other functions of TMJ, and maintains the posterior facial height & sagittal mandibular position. Thus treatment of condyle benefits the restoration of the mandibular width & midface projection.

When Condylar fractures occur ORIF of Condylar fractures should be performed first. This procedure would restore the sagittal mandibular position & benefit the treatment of mandibles & mid facial regions.

Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the management of panfacial fractures." British Journal of Oral and Maxillofacial Surgery 38.5 (2000): 472-476.

Owing to the importance of condylar fractures in the treatment of PFFs, the condyle is placed in the normal position before the correction of mandibular fractures can be ensured.

In some cases when a parasymphysis fractures occur with superolateral dislocation of condyle –

1. 1st manual manipulation of the displaced condyle

2. 2nd the reduction of parasymphysis

Li, Zhi, et al. "An unusual type of superolateral dislocation of mandibular condyle: discussion of the causative mechanisms and clinical characteristics."Journal of oral and maxillofacial surgery 67.2 (2009): 431-435.

During the treatment of PFFs , the occlusion helps in management & evaluation of treatment & also provides a reference for the proper reduction of maxillary factures.

The excellent contact between the segments from both the labial /buccal & lingual segments before & during fixation of mandibular fracture is very important, because even a minimal defects would increase the width of lower face, resulting in abnormal occlusions & leading to improper management of maxillary fractures.

Li, Zhi, et al. "Abnormal union of mandibular fractures: a review of 84 cases."Journal of oral and maxillofacial surgery 64.8 (2006): 1225-1231.

During the two years 1993–94, 57 maxillary fractures presented to Parma General Hospital’s Department of Maxillofacial Surgery.

9 of the patients underwent treatment of condylar fractures, all associated with other facial fractures.

Follow-up of 2-3 yrs –

no evidence of malocclusion , articular dysfunction, open bite or other skeletal or dental anomalies.

In all cases, the posterior facial height was restored.

A. Tullio, E. Sesenna. Role of surgical reduction of condylar fractures in the management of panfacial fractures .British Journal of Oral and Maxillofacial Surgery, Volume 38, Issue 5, October 2000, Pages 472-476

Asnani et al reported that If there is calvarial injury sequencing should start caudally and proceed cranially to achieve optimal results. If there is remarkable commiuation of mandible sequencing should start cranially to caudally.

Asnani, Smita Sonavane, Fawaz Baig , Srivalli Natrajan Usha. Panfacial Trauma - A Case Report. International Journal Of Dental Clinics 2010;2 (2): 35-38

Gruss et al advised reduction of zygomatic arch and malar projection first to reestablish the “Outer facial frame” before NOE or “Inner facial frame” is reduced.

Fonseca: Walker, Betts, Barber, Powers. Textbook of Oral and Maxillofacial Trauma, Third Eddition, Vol-1: 360

Dongmei He, Yi Zhang, Edward Ellis III, Panfacial fractures: Analysis of

33 cases Treated Late, J Oral & Maxillofacl Surg 65: 2459-2465, 2007.

When geometry of dental arches is disturbed

Kelly et al suggested reducing hard palate as

guide for mandibular reconstruction.

Merville recommended “Top to Bottom” sequence

in 1974 if NOE was involved in panfacial fracture.

Merville L: Multiple dislocations of the facial skeleton. J Maxillofac Surg 2:187, 1974.

Most common fracture site – symphysis & condyle.

Most common type of fracture – isolated linear fracture.

No correlation in incidence between mandibular fracture & other fractures

in PPF’s was observed.

PPF’s with simple mandibular fractures – fewer complications & better

treatment effects.

Significant difference between mandibular fractures in PPF’s & general

mandibular fractures were observed.

Most of the patients were treated with –

Bottom-up & Outside In & got satisfactory result.

Small % - difficult to treat – requires comprehensive classification.

RESULT HIGHLIGHTS

Considering the important role of the mandible in facial bones, the results have provided evidence of the feasibility of the "bottom-up and outside-in" approach in the treatment of PFFs. However, some PFFs remain difficult to treat. Thus, additional studies are necessary.

CONCLUSION

RESOURCES

Andrew C. Smith, Susan E. Barry, Inferior alveolar nerve damage following removal of mandibular third molar teeth. A prospective study using panoramic radiography. Australian Dental Journal 1997;42:3.

Wenig BL:Otolaryngologic Clinics of North America [1991, 24(1):93-101]

Dongmei He, Yi Zhang, Edward Ellis III:Panfacial Fractures: Analysis of 33 Cases Treated :Journal of Oral and Maxillofacial Surgery, Volume 65, Issue 12, December 2007, Pages 2459-2465

Sawhney CP, Ahuja RB.Faciomaxillary fractures in north India. A statistical analysis and review of management. Br J Oral Maxillofac Surg. 1988 Oct;26(5):430-4.

Markowitz BL, Manson PN: Panfacial fractures: Organization and treatment: Clin Plast Surg 16:105, 1989

Tullio, A., and E. Sesenna. "Role of surgical reduction of condylar fractures in the management of panfacial fractures." British Journal of Oral and Maxillofacial Surgery 38.5 (2000): 472-476.

RESOURCES

Li, Zhi, et al. "An unusual type of superolateral dislocation of mandibular condyle: discussion of the causative mechanisms and clinical characteristics."Journal of oral and maxillofacial surgery 67.2 (2009): 431-435.

Asnani, Smita Sonavane, Fawaz Baig , Srivalli Natrajan Usha. Panfacial Trauma - A Case Report. International Journal Of Dental Clinics 2010;2 (2): 35-38

Fonseca: Walker, Betts, Barber, Powers. Textbook of Oral and Maxillofacial Trauma, Third Eddition, Vol-1: 360

Merville L: Multiple dislocations of the facial skeleton. J Maxillofac Surg 2:187, 1974.

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