A Comparative Prospective Study of Two Different Treatment Sequences i.e. Bottom Up–Inside Out and Topdown–Outside in, in the Treatment of Panfacial Fractures

Abstract

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.

Panfacial Bone Fracture and Medial to Lateral Approach

“…Numerous studies have compared combinations of these reduction sequences. However, the efficacy of inside-out or outside-in sequences have not been assessed independently of bottom-to-top or top-to-bottom sequences [ 4 5 6 7 9 ]. The “bottom-to-top and outside-in” approach is the most widely used method in the panfacial bone reduction [ 2 4 5 7 9 ].…”

“…Fractures of the frontal bone, maxilla, zygomatic complex, nasoethmoid-orbital (NEO) region, and mandible are the most common [ 1 2 3 ]. In simpler terms, panfacial bone fractures involve the midface and mandible [ 4 ]. Even experienced surgeons find restoration of the original facial architecture difficult because of the severe degree of fragmentation and the loss of all reference segments that could guide the start of facial reconstruction [ 4 5 ].…”

“…In simpler terms, panfacial bone fractures involve the midface and mandible [ 4 ]. Even experienced surgeons find restoration of the original facial architecture difficult because of the severe degree of fragmentation and the loss of all reference segments that could guide the start of facial reconstruction [ 4 5 ]. Panfacial bone fractures are often accompanied by soft tissue trauma and destruction of the bony framework, which may result in malocclusion or facial deformities, including “dish” face deformity, loss of facial height or projection, increased facial width, and enophthalmos [ 6 ].…”

Surgical Management of Panfacial Fractures

“…Other authors recommend disimpaction and fixation of palatal fractures to use the maxillary dental arch as a template for the mandibular dental arch to maintain proper facial width. 21,25 To confirm proper reduction, normal bony landmarks and subtle cues from fracture alignment should be respected. During maxillomandibular fixation, preexisting dental wear facets can confirm proper occlusion.…”

“…Degala et al prospectively compared two common treatment sequences with 11 patients total (6 in the "top-down" group and 5 in the "bottom-up" group) and found that all patients were able to obtain normal occlusion, and there was no statistically significant difference in mouth opening, facial symmetry, or overall treatment outcome between the two groups. 25 The ideal approach should be individualized. The senior authors use a combination of these approaches and start with less comminuted segments with more visible reference points to ensure proper reduction and avoid compounding error by fixation of subsequent more comminuted and difficult fracture segments.…”