

Name : Mr. Bashir Ahmad Khan


Age : 45 Years

Gender : Male

Residence : Kupwara, J&K

OPD No. : 0543267

Telephone no. : 8803022315
Patient gives an alleged history of trauma to face due to
road traffic accident at his native place on 17/11/2022.
Patient was apparently alright 1 week back when he met with a
road traffic accident and was immediately rushed to a local
hospital where initial investigations and management was
done, then was referred to SMHS hospital, then was later
referred to Casuality omfs. Patient gives a history of multiple
injuries to head and face with a h/o brief loss of
consciousness, vomitting at the site of accident. He also has a
positive history of oral and nasal bleeding.
No h/o ear bleeding, headache, abdominal pain.
Patient doesn’t report any significant medical history.
Patient doesn’t report any significant dental history.
• Married
• Belongs to a lower middle class family.
• Patient is known to be a chronic tobacco chewer since 35 years.
• Sleep pattern:
• Apetite normal
• Bowel and bladder movements
• No significant family history.
Findings: Interpretation:

Built mesomorphic

Temperature Patient is afebrile to touch.

Pulse rate 78B/m taken on right radial artery.

Blood pressure 128/80 mmHg

Respiratory rate 18breaths/min

Palor, icterus, cyanosis, clubbing, absent
pedal edema

Covid-19 history negative

Patient is conscious, cooperative and well oriented to time, place
and person.
GCS= 15/15.
The necrotic area was
debrided, margins were
cleared and fresh
bleeding was induced.

The entire wound was

thoroughly cleaned with
hydrogen peroxide and
tinidazole.
Resuturing was done.
Mouth opening: 2fingers
Avulsed 31 32 41 42
Occlusion deranged
Floating maxilla
Premature contact seen in the
posterior molar region.
Degloving injury seen on the right
mandibular body region.
Frontal view.
Profile view.
Birds eye view.
Worms view
Pan facial trauma.
CBCT Imaging : coronal section
CBCT imaging: axial section showing
CBCT imaging: axial section
CBCT Imaging: coronal section
CBCT Imaging: 3D reconstruction of mandible.
CBCT imaging: 3D reconstruction of midface and lower face.
Distance from the infra-orbital margin to the posterior ledge:
23.1mm as measured on CBCT imaging.
CBC Coagulogram
Serum electrolytes LFTT
Triple Serology
CHEST X-RAY
ECG
 Pan-facial injuries involve trauma to
the upper, middle, and lower facial
bones.

 Poly-trauma is commonly associated

with these injuries; thus, treatment
often requires a team approach.

 After stabilization of the patient, early

and total restoration of facial form and
function should be the goal of the
maxillofacial surgeon.
Upper subunit: composed of frontal
bone.
Protects the frontal lobe.

Forms the roof of the orbit.

Encloses the cribriform plate of the

ethmoid.
Frontal sinus absorbs most energy and

may produce an anterior or posterior

table #.
A rudimentary frontal sinus on the

other hand causes forces to be directed

towards the orbital roof and anterior
cranial fossa.
 This model marks the
important horizontal and
vertical lines of elective
osteosynthesis in the repair of
the facial skeleton.
 The septovomerine complex
is weak. Central mid face
collapse is therefore a
common consequence of
severe mid facial injury.
 The mandible has good
structural integrity and well-
developed musculature.
 The specific problem arises in
establishing correct facial
width in associated
mandibular #.

The following landmarks can be used to reconstruct the
damaged areas because of fracture which may help in
establishing the proper positioning of facial skeleton:

1) Dental arches
2) Mandible
3) Spheno-zygomatic suture
4) Intercanthal region.
 In the treatment of a patient with multiple maxillofacial
injuries, differentiating injuries that require immediate
operative management from those for which the operation can
be delayed is critical.
 An immediate operation may be indicated to initially stabilise
a patient rather than to provide definitive treatment; therefore,
those procedures that require more extensive evaluation are
delayed to a later date when the patient is systemically stable.
 Occasionally, the immediate operation can be the definitive
procedure.
 The surgeon should be alert to the potential
for both obvious injuries and occult injuries
to other systems of the body.
 Note lacerations, incised wounds, abrasion,
contusions, injuries to underlying structures
(parotid, VII nerve), CSF leak, ophthalmic
injuries.
 The force necessary to create such severe
facial injuries is usually significant enough to
cause concomitant injury to the central
nervous system, chest, abdomen, pelvis, or
extremities.
Obtain information regarding

 location  extent

 Soft tissue loss  Structures involved

 Bone loss extent  Presence of dento-alveolar
injuries
Incisions for adequate exposure are based on:

Superior and lateral orbital region.

FZS.

Not required when bi-coronal flap is used.

Maxilla

Zygomatico maxillary buttress.

Mandible from ramus to symphysis.

Not recommended for comminuted fracture.
 Blind intubation

 Fiberoptic nasotracheal intubation

 Oral intubation.

 If MMF is being performed, this will need to be secured

through a gap in the teeth, or a procedure called a lateral
submental tracheal intubation

 Tracheostomy can be performed.

Tracheostomy
 As the energy imparted in #ing the mandible increases; the
location moves from subcondyle to neck to intraarticular #.
 Condyle # should be treated by ORIF

 In patients in whom minimal displacement of the condylar

fragments has occurred, clinical judgment must prevail.

 Access: detachment of masseter insertion on zygomatic arch

when a coronal approach is being used.

 Alternatively, retromandibular incision and transparotid

dissection is preferred

 Fixation of condylar # is important in establishing posterior

facial height and preventing ant open bite.
 Dr. Markowitz (1989) describes dividing the face into upper and lower halves
at the Le Fort I level and then dividing these halves into two facial units.
 The lower facial unit includes the occlusal and mandibular units and the upper
face the frontal unit.
 To simplify the reconstruction, these are also divided into central and lateral
zones.
 Frontal sinus # is treated by exenteration, obliteration or cranialisation.
 For occlusion: use arch bars, stabilize palatal # by mini plates/palatal splint ;I/o
or E/o mandibular fixation
 Fix horizontal mandible with rigid/semirigid fixation
 Use external approach for comminuted # of vertical mandible Otherwise fix
mini plate at ext oblique ridge
 Do open reduction of condyle for severe displacement/ dislocation or when
posterior facial height is reduced.
 The sequence of treatment would involve starting with
the inferior division of the central zone, repairing
occlusions and placing MMF, and fixing any palatal
fractures.
 Next, either the upper or the lower central zones could
be addressed usually completing the mandibular
reconstruction, both the central and the lateral, before
moving to the upper face.
 The lateral zone to the upper face then follows with
repair of the zygomatic fractures.
 Lastly, reconstruction of the LeFort I level would
reestablish the vertical height.
 At first glance, panfacial trauma can appear complex and
difficult to treat.
 The actual treatment involves a conglomeration of many
smaller procedures that are commonplace in maxillofacial
injuries.
 Adhering to a treatment protocol and treating each fracture as
a unit enable the surgeon to obtain reproducibly good results.
 Development of a step-by-step treatment plan prior to surgery
and adherence to the general principles of maxillofacial
trauma simplify the treatment of these patients.
 Microvascular free
flaps and regional flaps
replace both bone and
soft tissue to large
maxillofacial defects;
this introduces healthy,
unscarred, viable
tissues with their own
blood supply.
 Once the flaps have
been taken, they can
be manipulated and
recontoured. Bony
defects can also be
filled in and
recontoured by
autogenous bone.
• Open reduction and internal fixation of right condyle of
mandible using delta plate.
• Infraorbital rim reduction and fixation using 4 holed with gap
titanium miniplate.
• Orbital floor reconstruction using a titanium mesh.
• Reduction and fixation of right and left frontozygomatic suture
using 6 holed with gap miniplates.
• Soft tissue necrotic defect closure using promotional
advancement flap based on left mental artery.