Case reports

RAFAEL SARAIVA TORRES1 | GUSTAVO CAVALCANTI DE ALBUQUERQUE1 | JOEL MOTTA JUNIOR1 | VALBER BARBOSA MARTINS1 | MARCELO VINICIUS OLIVEIRA1 | INGRID SOANI AMARAL DE COUTO TENÓRIO2 | DENIS ESTEVES RAID2

Panfacial fractures are those that affect the upper, middle and lower face, making the treatment challenging. In some situations, the patients require multidisciplinary treatment because they have traumas in other regions of the body that preclude the treatment of all facial fractures. Cranioencephalic trauma, due to car accidents, often needs a neurosurgical approach. The use of biomaterials has been growing every day, like bioceramics, due to their characteristics, as an option for the reconstruction of bone defects. The objective of this article is to report a case of panfacial fracture treatment, with reconstruction, through a customized prosthesis (bioceramic), of a frontal region defect. The patient with multiple facial fractures was initially submitted to a surgical procedure to treat them. Later to correct a defect in the frontal region, it was installed a custom prosthesis. The patient has progressed well, with regression of complaints and correction of marked supraorbital defect. Thus, it can be concluded that panfacial fractures represent a complex challenge in the treatment of facial trauma. When they are accompanied with bone defects in the skull, the treatment through biomaterials and substances that can mimic the same characteristics of autogenous bone tissue has become an interesting option to be considered.

Keywords: Multiple trauma. Bone substitutes. Biocompatible materials.

1 Universidade do Estado do Amazonas, Programa de Residência em Cirurgia e Traumatologia

Buco-maxilo-facial (Manaus/AM, Brazil).

2 Universidade Federal do Amazonas, Hospital Getúlio Vargas, Programa de Residência em

Neurocirurgia (Manaus/AM, Brazil). How to cite: Torres RS, Albuquerque GC, Motta Junior J, Martins VB, Oliveira MV, Tenório ISAC, Raid DE. Treatment of panfacial fracture and late reconstruction of frontal defect: Case report. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9. DOI: https://doi.org/10.14436/2358-2782.7.1.043-049.oar

Submitted: November 09, 2018 - Revised and accepted: February 07, 2019

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

» Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Contact address: Rafael Saraiva Torres E-mail: saraivatorres@gmail.com

Panfacial fractures are those in which all facial bones are affected. They constitute the most complex and destructive traumatic disorders of the facial skeleton, involving all its pillars and supporting rings. Usually they affect the maxilla, mandible, zygomatic and naso-orbit-ethmoidal complexes, besides the frontal bone. They represent the most challenging cases for the oral and maxillofacial surgeon.1

They are usually associated with severe soft tissue injuries and lead to important esthetic-functional deformities, with disruption of facial appearance and ocular and dental occlusion symptoms.1 In most large centers, the main etiological agents are car accidents and physical aggressions, and trauma often requires a neurosurgical approach for the treatment of brain injuries.2,3

The diagnosis of panfacial fractures is made by clinical and imaging tests. Among the imaging exams, the gold standard is computed tomography (CT), which reveals the exact degree of bone displacement of fractures, as well as their relationship with the adjacent structures.3

In case of full thickness bone loss of the cranial vault, cranioplasty has the main objective of protecting the brain and correcting an extremely apparent esthetic deformity. Among the autologous materials used for this purpose, autologous grafts of the external plate of the parietal bone, ribs and iliac crest are highlighted.2,3 However, the increase in operative time, surgical trauma and the possible complications inherent to the approach of the donor area do not always allow their use. The new biomaterials and substances that mimic the characteristics inherent to autogenous bone tissue have been a constant search for bioengineering.4

The alloplastic materials most used today include are bioceramics, mainly hydroxyapatite and beta tricalcium phosphate. Beta tricalcium phosphate has been widely used as a carrier or framework in tissue engineering.3,4 Bioceramics are osteoconductive and have the advantage of not being reabsorbed, such as autogenous bone grafts. They are considered inductive bone substitutes and thus favor the bone regeneration, promoting their new formation by osteoconduction, and have good biocompatibility.2,3

Thus, the objective of the present study is to report a case of surgical treatment of panfacial fracture and reconstruction of a defect in the frontal region, resulting from a car accident, using a customized prosthesis (bioceramics), with good patient evolution. The entire treatment, from facial fractures to the planning and placement of prosthesis, is reported in detail.

Male patient, victim of a motorcycle accident, with 20 days of evolution, history of hospitalization due to serious injuries resulting from the accident, attended the service presenting a fracture in the anterior mandibular region (symphysis), left zygomatic maxillary complex, left naso-orbital-ethmoidal (NOE) fracture, besides depression in the left supraorbital region due to fracture of frontal bone after a motorcycle accident. Clinically, the patient was unable to lift the left eyelid, presented dystopia, diplopia, enophthalmos and loss of left malar projection (Fig 1A).

Computed tomography revealed fracture in the mandibular symphysis, fracture in the zygomatic maxillary pillar, frontozygomatic, infraorbital ridge, nasal bones, left NOE fracture and of the frontal bone (both anterior and posterior wall) above the left orbital region (Fig 1B).

Initially, the patient underwent a surgical procedure to reduce and fixate the facial fractures. Reduction and fixation were initially performed of fractures of the zygomatic maxillary complex, with fixation at three points, besides reduction of mandibular symphysis fracture with two plates (Fig 1C to 1F). The patient evolved well after the first surgery, with regression of preoperative complaints (Fig 2A to 2D). Transoperatively, there was no need to fixate the NOE fracture. Subsequently, to minimize the sequelae of facial trauma, it was proposed to manufacture a customized prosthesis (bioceramics) in the frontal region (Fig 2E and 2F). After making the prosthesis, the patient underwent a new surgical procedure, in partnership with the Neurosurgery team, due to loss of posterior frontal bone wall and direct communication with the dura mater. Bicoronal access and exposure of bone defect were performed and then the prosthesis was adapted and fixated with plates and screws of the 1.5 system (Fig 3A to 3D).

The patient has been followed for 12 months after reduction and fixation of facial fractures, with the resolution of all complaints initially presented, and 60 days after placement of the customized prosthesis, with total resolution of the defect in the frontal region. No signs of infection were observed in the region where the prosthesis was placed (Fig 3E to 3H).

Figure 1: A) Clinical aspect on the first visit. B) Reconstruction using computed tomography, showing multiple fractures of the face and defect in the left supraorbital region. C) Fracture fixation of the zygomatic maxillary abutment. D) Frontozygomatic suture fixation. E) Orbital plate for reduction and fixation of the infraorbital rim. F) Reduction and fixation of the mandibular symphysis fracture.

Figure 2: A) Clinical aspect after reduction of facial fractures. B) 3D reconstruction after reduction and fixation of facial fractures. C) Axial section after fixating the plate on the infraorbital rim. D) Coronal image showing the left orbital region after fixation of the orbital plate. E) Virtual planning for fabrication of customized prosthesis, in frontal view. F) Virtual planning for fabrication of customized prosthesis, in inferosuperior view.

Figure 3: A) Axial section of computed tomography, showing fracture of the frontal bone affecting the anterior and posterior wall. B) Defect in the frontal region, on the left. C) Visualization of the defect after bicoronal access. D) Placement of customized prosthesis. E) Axial section after prosthesis placement. F) Defect in the corrected frontal region. G) 3D reconstruction after placing the custom prosthesis. H) Postoperative aspect at 60 days after prosthesis placement.

Panfacial fractures are those that simultaneously involve the upper, middle and lower facial thirds. They constitute the most complex and destructive traumatic disorders of the facial skeleton, involving all its pillars and supporting rings.5 The concept of delayed treatment of panfacial fractures after full clinical recovery of the patient often results in severe secondary facial deformities. Treatment options for secondary deformities are never ideal, and the long-term result is poor. Thus, treatment should be performed as soon as possible, as long as it can be conducted safely.1

He et al.6 state that, if the treatment is not performed soon after trauma, the facial bones remain poorly united, the soft tissues shrink and contract and fibrosis occur, and all these factors hinder the later treatment. Surgical treatment of facial fractures reported in the present clinical case was performed approximately 25 days after trauma, since the patient suffered severe injuries to other organs and was only released for surgery after the mentioned period.

Kelly et al.7 advocated bone reconstruction of the facial skeleton as soon as possible, to minimize the retraction of soft tissues and non-anatomical consolidations of fractures. Regarding the surgical aspects, the fractures were already in the process of non-anatomical consolidation and formation of bone callus. Transoperatively there was a need for refracture, both in the mandibular symphysis region and in the zygomatic maxillary complex, for subsequent reduction and fixation in ideal position. Fracture fixation of the zygomatic maxillary complex was performed at three points (zygomatic maxillary abutment, frontozygomatic abutment and infraorbital ridge), with 1.5 system plates; and reduction of the mandibular symphysis fracture was performed with 1.5 and 2.0 system plates. There was no need for surgical treatment of the NOE fracture.

Cranioplasties can be performed with autologous bone, allogeneic (bone bank) or alloplastic material (bioceramics, titanium and polymethylmethacrylate). One advantage of using synthetic materials is to avoid the collection of other autogenic materials for grafting, such as bones, muscles and fat, which reduces the total time required for surgery.8 Considering the biomaterials used for prosthesis manufacturing, acrylic resin appears as a widely advantageous possibility for the professional and the patient.5 Since treatment onset, reconstruction of the frontal region defect by alloplastic material was planned.

At first, it was decided to make a polymethylmethacrylate (PMMA) prosthesis, due to its low cost and easy accomplishment. However, Cakarer et al.9 state that, although PMMA is being used in surgical practice, due to its high stability, it must be considered that the exothermic reaction can cause tissue necrosis, and that the presence of residual monomers causes inflammatory reactions, contributing to tissue destruction. Due to the direct proximity to the dura mater and considering the low control of formation of residual monomers and high risk of infection, the option to make a PMMA prosthesis was discarded.

Several authors describe that calcium phosphates and their derivatives, including beta tricalcium phosphate, act more directly on osteoblasts and have been extensively studied as bone substitutes.2,4,8 Considering the cited advantages, a prosthesis was requested from the company Eincobio®, customized by prototyping and made of porous ceramics (composed mainly of hydroxyapatite (HA) and beta-tricalcium-phosphate (B-TCP), in addition to other minerals). The presence of pores of various sizes is important for migration of both fibrous and bone tissue inside the prosthesis.8

Maricevich et al.8 state that a customized prosthesis has greater thickness than the titanium prosthesis, reducing the dead space between the prosthesis and the dura mater. It offers a perfect contour, but there is risk of infection, possibility of prosthesis exposure in case of low coverage of soft tissues, besides the cost, which can be an impediment to its use.10 There were no signs of infection, exposure of prosthesis or any other changes to date.

The surgical treatment of panfacial fractures is considered complex and requires maximum anatomical knowledge and surgical techniques by the oral and maxillofacial surgeon. The correction of bone defects resulting from trauma and other different etiologies is a challenge for modern medicine. The use of biomaterials for facial reconstruction instead of autogenic materials is an increasingly frequent reality. Bioceramics, considering their characteristics, have become an interesting choice.

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Ortop. 2008;43(3):59-68. 3. Hara T, Santos CA, Farias AF, Costa MJM, Cruz RJL.

Cranioplastia: parietal versus prótese customizada. Rev

Bras Cir Plást. 2011;26(1):32-6. 4. Souza DFM, Correa L, Sendyk DI, Burim RA, Naclério MG, Deboni MCZ. Efeito adverso do beta fosfato tricálcico com controle de potencial zeta no reparo de defeitos críticos em calvária de ratos. Rev Bras Ortop. 2016;51(3):346-52. 5. Souza RRL, Menezes LP, Silva Júnior EZ, Alencar MGM,

Vasconcelos BCE, Laureano Filho JR. Reconstrução de sequela facial por prótese interna acrílica. Rev Cir

Traumatol Buco-Maxilo-Fac. 2017;17(3):29-32. 6. He D, Zhang Y, Ellis 3rd E. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. 7. Kelly KJ, Manson PN, Vander Kolk CA, Markowitz BL,

Dunham CM, Rumley TO, et al. Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg. 1990;1(4):168-78. 8. Maricevich P, Mansur A, Peixoto A, Amando J,

Pantoja E, Braune A, et al. Cranioplastias: estratégias cirúrgicas de reconstrução. Rev Bras Cir Plást. 2016;31(1):32-42. 9. Caraker S, Selvi F, Isler C, Olgac V, Keskin C. Complication of polymethylmethacrylate bone cement in the mandible. J Craniofac Surg. 2010;21(4):1196-8. 10. Maia M, Klein ES, Monje TV, Pagliosa C. Reconstrução da estrutura facial por biomateriais: revisão de literatura. Rev Bras Cir Plást. 2010; 25(3):566-72.