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Panfacial Fracture Surgical Approach, Bottom Up– Outside In versus Top Down– Inside Out. Prospective Clinical Study.

Objectives: The current study aim was to compare two surgery approaches, bottom-up outsidein and top-down inside-out, for the treatment of panfacial fracture. Material & Methods: Twelve male panfacial fracture patients were randomly divided into two groups. Group 1 involved six patients treated in Bottom Up– Outside In sequence, and group 2 involved six patients treated in Top Down– Inside Out sequence. The treatment plan was set based on Computerized Tomography (CT) images. Clinical evaluation of final treatment outcome was reported postoperatively based on facial contour, occlusion, and maximal mouth opening. Data was collected and analysed statistically. Results: The final treatment outcome in each group was 83.7% excellent, and 16.3% good. Insignificant difference resulted between the study groups after postoperative assessment regarding the final treatment outcome (p=1.00), and the postoperative assessment of Paraesthesia (p=0.269). Conclusion: The current study found that both bottom-up outside-in and top-down inside-out sequences for the treatment of panfacial fracture have similar clinical outcomes. (274) Shereen W. Arafat and Mohamed A. Elbaz E.D.J. Vol. 68, No. 1 Proper management of panfacial fractures usually starts with proper physical examination and accurate imaging. Examination of the face is performed visually and manually with careful detection of oedema and ecchymosis, facial asymmetry, trismus, and malocclusion. Bony stepoffs, crepitation, areas of tenderness, and midfacial mobility are detected. Proper palpation of the naso-ethmoid region, the palate, and the orbit is mandatory. Visual evaluation by an ophthalmologic consultant is requested. Computed tomography is a valuable method in determining the treatment plan. Three-dimensional reconstructions play a major role in surgical planning. With the beginning of 1980s and during 1990s, craniomaxillofacial surgeons suggested and applied the concept of broad exposure and visualization of the fracture which in turn affected the sequence of repair. (6) Maxillofacial Surgeons usually follow the “bottom upoutside-in” or “top downinside-out” approach. (7) “Bottom up outside-in” approach starts the reduction and fracture fixation for the mandible then proceed to the frontal bone, and then to the zygomatico-maxillary complex, maxilla, and NasoOrbital-Ethmoidal region (NOE). This approach is the most commonly used in the reduction of panfacial bone. (8,9) While, “top downinsideout” approach have proved good occlusion and mouth opening when compared to the “bottom up outside-in” approach. This approach starts with proper reduction of the maxillary alveolar ridge by reduction and repositioning of the facial buttress. Then, the maxillary alveolar ridge can act as a stable baseto reposition and adjust the mandible in three dimensions. (10) Facial reconstruction approaches and sequence of management have considerable controversy.(11) Therefore, In the current study we performed a prospective study for patients with panfacial fractures to compare the surgery approaches. PATIENTS AND METHODS Twelve male panfacial fracture patients aged from 23 to 48 years were selected for the current study and randomly divided into two groups. Group 1 involved six patients treated in Bottom Up– Outside In sequence, and group 2 involved six patients treated in Top Down– Inside Out sequence. Patients were selected from Dar El-Fouad Hospital Emergency Department where injuries resulted from road traffic accidents. Patients were included in the current study if they had multiple fractures involving mandible, maxilla, and zygomaticomaxillary complex. Fractures of the nasal-orbitalethmoid (NOE) region and/or frontal bone may be involved as well. The selected patients provided written informed consent for involvement in the study and for the publication of their cases. The treatment plan was set based on Computerized Tomography (CT) images. The degree of facial deformities and malocclusions were evaluated, and the surgical incisions were planned preoperatively. Within the 5 days post-injury, the patient went to the operating room of Dar El-Fouad Hospital for open reduction and internal fixation. Local incisions were applied in addition to the coronal incisions. For patients of group 1, treatment started with reduction and fixation of mandibular fractures to restore facial height and projection, then the zygomatic arches were reduced to act as guidance to the zygomas to be reduced and fixed together with the zygomaticomaxillary and spheno-zygomatic sutures. Both Zygomatic Complex and nasalorbital-ethmoid (NOE) fractures were stabilized followed by maxilla and the orbital rims were realigned to adjust the transverse facial dimension. Patients of group 2, after reduction and fixation of frontal sinus, nasal-orbital-ethmoid (NOE) fractures, and orbital rims were stabilized followed by repair of maxilla. Zygomatic Complex and nasal-orbitalethmoid (NOE) fractures were stabilized followed PANFACIAL FRACTURE SURGICAL APPROACH, BOTTOM UP–OUTSIDE IN VERSUS TOP DOWN– INSIDE (275) by the zygomatic arches. Finally, reduction and fixation of mandibular fractures were performed. For both groups, bony defects founded in the skull and orbital floor were reconstructed with titanium meshes. Wound closure and drainage were properly performed. The patient started full liquid diet on postoperative day one and imaging was performed. Proper oral hygiene with chlorhexidine rinses and maxillary sinus precautions were performed. Hospital discharging was on postoperative day five. Fig. (1) Panfacial fracture case, A: Intraoperative photograph showing the coronal flap and fracture line. B: Intraoperative photograph showing the plate fixation of the fracture line. C: Intraoperative photograph showing inferior orbital rim plate fixation. D: Intraoperative photograph showing mandibular angle plate fixation. E& F: Pre-operative 3D CT images. (276) Shereen W. Arafat and Mohamed A. Elbaz E.D.J. Vol. 68, No. 1