Panfacial fractures (PFFs) involve all three areas of the face: the frontal bone, midface, and mandible. However, when two of these three areas are involved, the term “panfacial bone fracture” is used in practice or in articles. In this study fractures involving two or three facial areas were included. The management of PFFs can be extremely challenging, even for experienced surgeons, partly because in many cases, there are no stable structures available to re-establish bone continuity. PFFs repair requires a systematic approach with a thorough understanding of the sequence; however, it is often difficult to determine the ideal sequence for treating these complex fractures.

Several authors have attempted to systemize the approach for managing PFFs in a stepwise manner. Craniofacial surgeons begin reconstruction with the frontal bone and proceed to the midface, using the upper face as a template for the lower face [1]. This method is named the “top-bottom” sequence. However, oral maxillofacial surgeons believe that the top-bottom sequence is inadequate because it could result in malocclusion when applied on PFFs that involve two occlusal parts: the maxilla and mandible. As a result, the “bottom-top” sequence has been suggested. The bottom-top sequence focuses on the mandible, which is the strongest bone of the facial skeleton and provides a buttress that can be accurately related to the cranial vault through rigid internal fixation [2].

Some surgeons prefer the bottom-top approach, while others use the top-bottom method. There are still other arguments about “inside-out” versus “outside-in” methods. However, performing surgery by applying a unidirectional sequence to PFFs is much more difficult in practice because every patient has a different type and severity of fracture. PFF surgery is usually performed by plastic reconstructive surgery (PRS) or oral maxillofacial surgery (OMS) specialists, and two specialists mainly manage these cases, depending on the fracture area. Consequently, sequence selection may differ between two specialists.

In this study, a review of the current literature on sequence selection for PFFs was conducted to determine and compare how the sequence used was selected by two specialists. Another objective was to review PFFs fixation sequence in clinical cases.

PFFs include fractures involving the upper, middle, and lower thirds of the face, including multiple fractures of the mandible, maxilla, zygomaticomaxillary complex (ZMC), frontal bones, and naso-orbito-ethmoid (NOE) regions. Historically, these fractures were treated conservatively, which led to significant posttraumatic problems, including crippling malocclusion, significant increase in facial width, and decreased facial projection [1]. Treatment of PFFs can be difficult because of the apparent loss of all references for facial skeleton reconstruction, particularly in fractures interrupting the maxillary and mandibular arches, which should constitute recognizable occlusion and bone continuity [24]. As with other multiple fractures, it is necessary to outline a detailed plan before surgery to determine the buttresses to be reduced and the sequence of reduction for successful surgical management of PFFs.

The literature review highlighted sixteen studies that reported the “bottom-top and outside-in” sequence. The mandible provides a foundation and firm framework for reconstructing the craniofacial skeleton because it is a long, solitary, and powerful bone in the face [6,10,15]. By selecting the mandible as the first point of fixation in the PFFs, the width, height, and projection of the lower face were determined through the body, condyle/ramus, and symphysis areas [8,11,16]. Additionally, the mandible maintains continuity between the lower third and the entire facial skeleton by connecting with the maxilla and occlude the skull base via the temporomandibular joint [5]. The midface was fixed using the outside-in principle after the bottom-top anatomic reduction [14]. Specifically, fixation of the midface begins in the ZMC region and ended in the NOE region. For reconstruction, the ZMC had more definitive landmarks than the NOE complex [7]. An additional benefit of ZMC fixation is that it allows control over the transverse and anteroposterior dimensions as well as stability of the lateral pillar [17]. In contrast to other studies, Pau et al. [12] used a bottom-top and inside-out sequence in their intracranial reduction procedure because of nasal bone dislocation into the anterior skull.

The top-bottom sequence was used and achieved good results in three studies. Kim et al. [18] used a top-bottom sequence and preferred the inside-out approach in rare cases involving frontal bone fractures near the nasofrontal junction. In cases with open wounds near the frontal bone fracture site, but no comminuted fracture in the NOE area, they began the reduction from the center of the frontal bone through laceration. Vasudev et al. [19] used the top-bottom technique and determined that this approach enables the proper restoration of both form and function. Because of their familiarity with midface reduction, Yun and Na [20] first applied arch bars and then reduced the frontal bone fracture, followed by midface and mandible fractures in this sequence. Three studies described both “top-bottom, inside-out” and “bottom-top, outside-in” sequences [21–23]: Degala et al. [21] compared the bottom-top, inside-out sequence with the top-bottom, outside-in sequence in the treatment of PFFs to evaluate the outcome of these approaches. Similar clinical outcomes were observed in the 11 cases in that study. The other two studies determined the sequence according to the case [22,23].

The surgical sequence favored by OMS surgeons who specialize in mandibular fractures may differ from that favored by PRS surgeons who are accustomed to operating on mid-facial fractures or by neurosurgeons who deal with skull fractures. These controversies are caused by the difference in the frequencies of certain fractures encountered in a particular field. The total number of patients reviewed in the 22 articles was 749, of which 370 were managed by OMS and 379 by PRS. Among these patients, 249 had clearly documented fracture sites in OMS and 112 in PRS. Furthermore, 234 of the 249 (94.0%) OMS-managed patients had fractures involving the lower face area, whereas only 45 of 112 (40.2%) PRS-managed patients had lower face fractures. This shows that the fracture types or locations generally encountered by each specialist may be different. Consequently, each specialist was compelled to assert a distinct sequence.

In actual clinical practice, most cases requiring surgery usually involve fractures of only two of the three parts (upper, middle, and lower) of the facial skeleton, rather than severe fractures of all three parts. This causes a dilemma regarding whether upper or lower fractures should be prioritized during surgical reduction. Based on this, PFFs can be broadly classified as mid-lower (maxillomandibular) or upper-middle (fronto-orbital, fronto-zygomatic, or fronto-maxilla) facial bone fractures. The use of this classification prevents confusion when deciding on a bottom-top or top-bottom surgery sequence. Maxillo-mandibular fractures occurring in the mid-lower facial bones centered on the occlusal surface should be reduced using the bottom-top sequence, as this first reduces the mandibular buttress, thereby restoring the occlusal surface. In contrast, PFFs that mainly involve the frontal bone and mid-facial bone, which is the upper-middle part of the facial bone, should be treated using the top-bottom sequence, which restores the transverse frontal buttress first.

However, in PFFs, a straightforward operation may not always be achieved, even when the above methods are considered. Therefore, a universal concept that can effectively deal with any PFFs is required. For example, when we combined multiple pieces of a puzzle, we did not put them in a unidirectional manner. The easiest way to put together a puzzle is to set the borders of the puzzle first, then place the most reliable pieces in that position, and then place the large pieces before placing the smaller pieces. Similarly, when aligning multiple facial bone fractures, it is best to first align the buttress that determines the width and height of the face; second, align a reliable fracture fragment to its original position; and third, align a thick, large, and stable bone fragment rather than a small bone fragment.

Bottom-top sequencing was mainly used in OMS specialists, and top-bottom sequencing was used at a similar rate by two specialists in literature review. In our experience, however, it was hard to consistently implement unidirectional sequence suggested by a literature review. We realigned the reliable and stable buttresses first with tailoring individually for each patient, rather than proceeding in the unidirectional sequence like bottom-top or top-bottom and achieved a good outcome.