![]() 5 This was followed by descriptions of the buttresses in 1916 by Cryer 6, and by illustrations of the vertical pillars and horizontal buttresses. Historically, the lines of weakness were first described by LeFort in 1901. The primary goal would be to restore the occlusal relationship and then the spatial relationship between the occlusal structures and the skull base. In actuality, the best course of action is to follow a combined process. 3 4 These two thought processes have permeated the literature and teaching for decades. The outside-in, or top-down, mentality would be reconstructing the outer facial frame and the bony pillars, such as the zygomatic arch and the frontal areas, and then addressing the interfacial frame. This would allow the occlusal relationship to be restored and then “built out” from that process. The inside-out thought process is reconstructing the maxillary–mandibular unit as the first major step and then focusing on the midface structures. There are different philosophies about inside-out or bottom-up versus outside-in or top-down approaches. ![]() Once the airway has been established, the repair of panfacial injuries follows a systematic approach. Of course, there are concerns about postoperative tracheostomy-related complications however, the risk of tracheostomy is relatively low when compared with the risk of airway management postoperatively. A tracheostomy allows the tube to be away from the structures being repaired and also has postoperative control of the airway. Submental intubation has been shown to be a safe approach with the tube out of the way, but the postoperative issues in regards to nasal packing and mandibular–maxillary fixation still exist. 2 There can be significant edema or packing within the nose in combination with mandibular–maxillary fixation that also leads to concern about maintaining airway patency. Nasal intubation is often possible however, with complex nasal and naso-orbito-ethmoid fractures, in addition to mandibular and palatal fractures, there is concern for postoperative management of the airway. Oral intubation is possible when there is an absence of occlusion or absent teeth that allows the oral tube to be placed posteriorly in the mouth. 1 The latter three of these intubations allows for mandibular–maxillary fixation with full dentition. There are four established mechanisms for the airway: oral intubation, nasal intubation, submental intubation, and a tracheostomy. One of the primary concerns with regards to the repair of panfacial fractures is airway management. Principles of Approach to Panfacial Fracture
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