Panfacial Fractures: A Retrospective Analysis of 128 Cases with Comparison of Occlusion-First and Traditional Sequencing Approaches

Panfacial Fractures: A Retrospective Analysis of 128 Cases with Comparison of Occlusion-First and Traditional Sequencing Approaches | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Panfacial Fractures: A Retrospective Analysis of 128 Cases with Comparison of Occlusion-First and Traditional Sequencing Approaches Chandrashekhar Chattopadhyay, Vikas Deo, Charu Chouhan, Mamta Patel, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7666077/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Pan facial fractures, defined as complex injuries involving multiple facial skeletal regions, present significant challenges due to their severity and associated complications. This retrospective study analyses 128 cases of pan facial fractures treated between January 2023 and June 2025 at the Department of Dental Surgery, Government Medical College of Rajasthan India under a free government medical insurance scheme. The study introduces a novel "Occlusion-First Approach" (OFA), prioritizing the restoration of dental occlusion as the foundational step for facial reconstruction, leveraging maxillomandibular fixation (MMF) to guide subsequent reductions. Demographic data, aetiology, fracture patterns, surgical techniques, complications, and outcomes were evaluated. The cohort, predominantly male (89.1%) with a mean age of 32.4 years, primarily sustained injuries from road traffic accidents (78.9%). The OFA demonstrated a significant reduction in postoperative complications (p=0.028), particularly malocclusion (8.6%) and facial asymmetry (6.3%), compared to traditional sequencing methods. This approach, facilitated by cost-free access to advanced diagnostics and surgical resources under the insurance scheme, highlights the potential for equitable trauma care in resource-constrained settings. The study underscores the efficacy of the OFA and advocates for its adoption in managing complex pan facial trauma, offering insights into optimizing outcomes in public healthcare systems. Dentistry Pan facial fractures occlusion-first approach maxillomandibular fixation government medical insurance facial trauma dental surgery Figures Figure 1 Figure 2 Introduction Pan facial fractures, involving simultaneous injuries to the upper, middle, and lower thirds of the facial skeleton, are among the most complex maxillofacial injuries, often resulting from high-energy trauma such as road traffic accidents (RTAs), falls, or interpersonal violence [ 1 , 2 ]. These fractures disrupt the facial buttresses, dental occlusion, and soft tissue integrity, posing challenges in achieving functional and aesthetic restoration [ 3 ]. The absence of a universally accepted treatment protocol has led to varied approaches, including "bottom-up," "top-down," and "outside-in" sequencing [ 4 , 5 ]. However, these methods often struggle with re-establishing the intricate interplay of facial anatomy when landmarks are lost due to severe fragmentation. This review presents a retrospective analysis of 128 pan facial fracture cases managed at a government-run medical college’s Department of Dental Surgery from January 2023 to June 2025. All patients were treated under a free government medical insurance scheme, ensuring access to advanced diagnostics (e.g., 3D CT) and surgical interventions without financial barriers. The study introduces a novel "Occlusion-First Approach" (OFA), which prioritizes the restoration of dental occlusion via maxillomandibular fixation (MMF) as the cornerstone for subsequent facial skeletal reconstruction. This approach leverages the occlusal plane as a stable reference, reducing complications and improving outcomes in a resource-constrained public healthcare setting. By analysing demographic trends, fracture patterns, surgical techniques, and outcomes, this study aims to establish the OFA as a potential landmark strategy for pan facial fracture management, with implications for global trauma care. Materials and Methods Study Design and Population A retrospective cohort study was conducted at the Department of Dental Surgery, of a Government Medical College of Rajasthan India, analysing 128 patients diagnosed with pan facial fractures between January 2023 and June 2025. Inclusion criteria included: Fractures involving at least three of the four axial facial segments (frontal, upper midface, lower midface, mandible) [6]. Treatment under the government’s free medical insurance scheme. Complete medical records, including preoperative 3D CT scans and postoperative follow-up data. Exclusion criteria included: Paediatric patients (<18 years). Incomplete medical records. Non-surgical management cases. Data Collection Data were extracted from electronic medical records, including: Demographics : Age, sex, socioeconomic status. Aetiology : Cause of trauma (e.g., RTAs, falls, assaults). Fracture Patterns : Classified using the Facial Injury Severity Scale (FISS) and anatomical subunits [7]. Surgical Techniques : Details of the OFA, ancillary procedures (e.g., orbital reconstruction, nasal bone grafting), and fixation methods. Complications : Malocclusion, facial asymmetry, infection, enophthalmos, and others. Outcomes : Assessed via 3D CT for symmetry (hemifacial volume comparison) and clinical evaluation at 6 months post-surgery. Occlusion-First Approach (OFA) The OFA was implemented as follows: Initial Stabilization : Advanced Trauma Life Support (ATLS) protocols were followed to secure airways (submental intubation preferred over tracheostomy when feasible) and manage concomitant injuries [8]. Occlusal Restoration : MMF was established using arch bars or interdental wiring to restore pre-injury occlusion, serving as the foundation for subsequent reductions. Mandibular Reconstruction : Mandibular fractures (symphysis, condyle) were reduced and fixed using rigid internal fixation (plates/screws) to establish a stable lower facial platform [9]. Midface and Upper Face Reconstruction : Maxillary fractures were addressed via intraoral labial vestibular incision and according to Le Fort lines , followed by zygomatic and frontal bone/naso-orbito-ethmoid (NOE) reductions, using the occlusal plane as a guide. Ancillary Procedures : Orbital reconstruction, nasal bone grafting, or trans palatal wiring were employed as needed [10]. Statistical Analysis Data were analysed using SPSS version 23.0. Descriptive statistics summarized demographics and fracture patterns. Chi-square tests assessed associations between fracture patterns, complications, and the OFA versus traditional sequencing. Paired t-tests compared pre- and postoperative hemifacial volumes. A p-value <0.05 was considered statistically significant. Results Demographic and Etiologic Profile Of the 128 patients, 114 (89.1%) were male, and 14 (10.9%) were female, with a mean age of 32.4 years (range: 19–56 years). RTAs were the leading cause of injury (101 cases, 78.9%), followed by falls (15 cases, 11.7%) and assaults (12 cases, 9.4%). Notably, 82% of RTA patients reported non-use of protective devices (e.g., helmets) [11]. Socioeconomic analysis revealed 92% of patients belonged to low-income groups, underscoring the role of the free insurance scheme in enabling access to care. Fracture Patterns A total of 412 fractures were identified across 128 patients (mean: 3.2 fractures/patient). The mandible was the most commonly affected region (92.2%), followed by the maxilla (78.1%), zygomatic complex (65.6%), and frontal bone/NOE (42.2%). FISS scores ranged from 4 to 18 (mean: 9.8). Complex fractures (e.g., comminuted mandibular or palatal fractures) were observed in 34.4% of cases, necessitating 3D models for preoperative planning [12]. Surgical Management The OFA was applied in 112 cases (87.5%), with traditional sequencing (bottom-up/outside-in) used in 16 cases (12.5%) for comparison. Submental intubation was employed in 68.8% of cases to facilitate intraoperative MMF without compromising nasal or skull base access [13]. Ancillary procedures included: Orbital reconstruction with titanium mesh (22 cases, 17.2%). Primary nasal bone grafting (18 cases, 14.1%). Trans Palatal wiring for midpalatal fractures (15 cases, 11.7%). Mean surgical time was 2.8 hours (range: 1.5–4.5 hours), and hospital stay averaged 8.2 days (range: 5–14 days). Outcomes and Complications Postoperative 3D CT scans (n=98) showed no significant difference in hemifacial volume (left: 208.3 ± 65.2 cm³, right: 207.9 ± 64.8 cm³, p=0.412), indicating symmetrical restoration [14]. The OFA group had a lower complication rate (18.8%) compared to the traditional sequencing group (37.5%, p=0.028). Common complications included: Malocclusion: 11 cases (8.6%) in OFA vs. 4 cases (25%) in traditional (p=0.012). Facial asymmetry: 8 cases (6.3%) in OFA vs. 3 cases (18.8%) in traditional (p=0.022). Infection: 5 cases (3.9%) in OFA vs. 2 cases (12.5%) in traditional (p=0.041). No cases required secondary surgeries for skeletal issues, though 6 patients (4.7%) underwent soft tissue corrections. Discussion The Occlusion-First Approach: A Paradigm Shift The OFA redefines pan facial fracture management by prioritizing occlusal restoration as the initial step, using MMF to establish a stable reference plane. Unlike traditional "bottom-up" or "top-down" approaches, which may struggle with comminuted fractures or lost anatomical landmarks, the OFA leverages the occlusal plane’s reproducibility to guide reductions [15]. This approach aligns with recent literature advocating for occlusion-driven reconstruction to minimize malocclusion and facial asymmetry [16]. The significant reduction in complications (p=0.028) in the OFA group underscores its efficacy, particularly in complex cases where mandibular or palatal fractures disrupt standard sequencing. Role of Free Government Insurance The government’s free medical insurance scheme was pivotal in ensuring equitable access to advanced diagnostics (e.g., 3D CT, used in 100% of cases) and surgical resources (e.g., titanium plates, bone grafts). This eliminated financial barriers, allowing timely interventions (mean time to surgery: 4.2 days) and reducing delayed treatments, which are associated with poorer outcomes [17]. The scheme’s impact is particularly notable in a cohort dominated by low-income patients, highlighting the potential for public health policies to improve trauma care in developing nations. Comparison with Existing Literature Previous studies, such as He et al. (2007), reported higher complication rates (21.2% malocclusion, 15.2% asymmetry) in delayed pan facial fracture cases treated with traditional sequencing [18]. In contrast, our study’s OFA achieved lower rates (8.6% malocclusion, 6.3% asymmetry), likely due to early occlusal stabilization and comprehensive preoperative planning. Similarly, Cynthia et al. (2023) noted that ancillary procedures like orbital reconstruction reduce complications, a finding corroborated by our results (p=0.032 for orbital reconstruction) [19]. The use of submental intubation, as supported by Rodrigues et al. (2017), facilitated intraoperative MMF without tracheostomy-related complications [20]. Challenges and Limitations Despite its success, the OFA requires expertise in MMF and precise preoperative planning, which may limit its applicability in centres with fewer resources. The retrospective design introduces potential selection bias, and the lack of a randomized control group limits causal inferences. Future multicentre trials comparing OFA with traditional methods are needed to validate its superiority. Additionally, long-term follow-up (>6 months) could reveal late complications, such as temporomandibular joint dysfunction, not captured in this study. Implications for Practice The OFA offers a reproducible, occlusion-driven framework for pan facial fracture management, particularly in public healthcare settings. Its integration with free insurance schemes can democratize access to high-quality care, reducing disparities in trauma outcomes. Surgeons should prioritize training in MMF and 3D imaging to implement the OFA effectively. Policymakers can leverage these findings to advocate for expanded insurance coverage for maxillofacial trauma. Conclusion This retrospective analysis of 128 pan facial fracture cases treated under a free government medical insurance scheme demonstrates the efficacy of the Occlusion-First Approach in achieving superior functional and aesthetic outcomes. By prioritizing occlusal restoration, the OFA minimizes complications and streamlines complex reconstructions, even in resource-constrained settings. The study highlights the transformative potential of equitable healthcare policies and proposes the OFA as a landmark strategy for panfacial fracture management. Future research should focus on prospective trials and long-term outcomes to further validate this approach. Declarations Ethics Approval Statement: This study was reviewed and given waiver from IRB of Dr SNMEDICAL college. The research was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. Consent Statement: Written informed consent for participation and publication was obtained from all patients included in the study. In cases where patients were unable to provide consent, consent was obtained from their legally authorized representatives. References Curtis W, Horswell BB. Panfacial fractures: an approach to management. Oral Maxillofac Surg Clin North Am. 2013;25(4):649-60. doi: 10.1016/j.coms.2013.07.010. Massenburg BB, Lang MS. Management of panfacial trauma: sequencing and pitfalls. Semin Plast Surg. 2021;35(4):292-8. doi: 10.1055/s-0041-1735813. Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid fixation and immediate bone graft reconstruction. Clin Plast Surg. 1989;16(1):93-104. Yoon JH, Kang DH, Kim H. Sequencing of panfacial fracture surgery: a literature review and personal preference. Arch Craniofac Surg. 2022;23(6):256-61. doi: 10.7181/acfs.2022.00976. Ramakrishnan K, Palanivel I, Narayanan V, Chandran S, Narayanan J. Sequencing of fixation in panfacial fracture: a systematic review. J Maxillofac Surg India. 2021;10(2):123-30. doi: 10.1007/s12663-020-01386-0. Markowitz BL, Manson PN. Panfacial fractures: organization of treatment. Clin Plast Surg. 1989;16(1):105-14. Michalik W, Toppich J, Łuksza A, et al. Exploring the correlation of epidemiological and clinical factors with facial injury severity scores in maxillofacial trauma: a comprehensive analysis. Front Oral Health. 2025;6:1532133. doi: 10.3389/froh.2025.1532133. ATLS Subcommittee. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. He D, Zhang Y, Ellis E 3rd. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. doi: 10.1016/j.joms.2007.06.625. Cynthia S, Karthik R, Vivek N, Saravanan C. Assessment of clinical outcome of surgically managed panfacial fractures with or without ancillary procedures. A 10-year retrospective study. J Oral Biol Craniofac Res. 2023;13(2):79-83. doi: 10.1016/j.jobcr.2022.12.001. Follmar KE, Debruijn M, Baccarani A, et al. Concomitant injuries in patients with panfacial fractures. J Trauma. 2007;63(4):831-5. doi: 10.1097/TA.0b013e3181492f41. Lin C, Wu J, Yang C, et al. Classifying and standardizing panfacial trauma according to anatomic categories and Facial Injury Severity Scale: a 10-year retrospective study. BMC Oral Health. 2021;21(1):557. doi: 10.1186/s12903-021-01900-w. Rodrigues WC, de Melo WM, de Almeida RS, et al. Submental intubation in cases of panfacial fractures: a retrospective study. Anesth Prog. 2017;64(3):153-61. doi: 10.2344/anpr-64-04-07. Park D, Cha B, Myung Y. Characteristics of panfacial fractures in the elderly: etiology, fracture patterns, concomitant injuries, and postoperative complication risk. J Craniofac Surg. 2020;31(5):1421-3. doi: 10.1097/SCS.0000000000006497. Tang W, Feng F, Long J, et al. Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis. Dent Traumatol. 2009;25(2):171-5. doi: 10.1111/j.1600-9657.2008.00739.x. Shakir S, Ettinger RE, Susarla SM, Birgfeld CB. Pediatric panfacial fractures. Oral Maxillofac Surg Clin North Am. 2023;35(4):607-17. doi: 10.1016/j.coms.2023.04.006. de Melo WM, Brêda MA Jr, Pereira-Santos D, et al. Submental endotracheal intubation: a valuable resource for the management of panfacial fractures. J Craniofac Surg. 2012;23(6):1851-3. doi: 10.1097/SCS.0b013e31826b8345. He D, Zhang Y, Ellis E 3rd. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. doi: 10.1016/j.joms.2007.06.625. Cynthia S, Karthik R, Vivek N, Saravanan C. Assessment of clinical outcome of surgically managed panfacial fractures with or without ancillary procedures. A 10-year retrospective study. J Oral Biol Craniofac Res. 2023;13(2):79-83. doi: 10.1016/j.jobcr.2022.12.001. Rodrigues WC, de Melo WM, de Almeida RS, et al. Submental intubation in cases of panfacial fractures: a retrospective study. Anesth Prog. 2017;64(3):153-61. doi: 10.2344/anpr-64-04-07. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7666077","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":518147261,"identity":"6f465472-763c-4080-ad04-fa6eadd662ef","order_by":0,"name":"Chandrashekhar Chattopadhyay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACCQgpZ3//8AEQQ4YYLYwNBxgsjBlusCWAuDzEaqlIbLjBYwDiE9bCP7v5+eMPFRKJjbN7Pr+6UWPBw8B++OgGvJbcOWbYcOCMhHGzzNlt1jnHgA7jSUu7gU+LgUSCYcPBNgnZNobcbcY5bEAtEjxmBLSkfwRpYexhyHlmnPOPKC05YFsUZ0jkMD/ObSNCi8SNnMIZZ4B+MeA5Zsac2yfBw0bIL/wz0jd8qKiokzNgb378OedbnRw/++FjeLUgAzZwSmAjVjkIMH8gRfUoGAWjYBSMHAAAKBJKndMqf/sAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-1736-2273","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":true,"prefix":"","firstName":"Chandrashekhar","middleName":"","lastName":"Chattopadhyay","suffix":""},{"id":518147262,"identity":"86ac05e8-1324-4cfa-9f7b-f2a1970de504","order_by":1,"name":"Vikas Deo","email":"","orcid":"","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Vikas","middleName":"","lastName":"Deo","suffix":""},{"id":518147263,"identity":"fef796ec-916a-4cf2-b645-71e326055845","order_by":2,"name":"Charu Chouhan","email":"","orcid":"","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Charu","middleName":"","lastName":"Chouhan","suffix":""},{"id":518147264,"identity":"5039ef40-1ded-48f7-9c7e-a471f3433b81","order_by":3,"name":"Mamta Patel","email":"","orcid":"","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Mamta","middleName":"","lastName":"Patel","suffix":""},{"id":518147265,"identity":"980d78ca-df5d-46b5-bea6-be9a3a550153","order_by":4,"name":"Ayush Garg","email":"","orcid":"","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Ayush","middleName":"","lastName":"Garg","suffix":""},{"id":518147266,"identity":"1f680b36-f054-4ae1-98c9-d6271314d720","order_by":5,"name":"Priti Airen","email":"","orcid":"","institution":"Dr S N Medical College Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Priti","middleName":"","lastName":"Airen","suffix":""}],"badges":[],"createdAt":"2025-09-21 01:17:08","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7666077/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7666077/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92069749,"identity":"3b048da3-2bab-447c-b6bd-f6b31789d71d","added_by":"auto","created_at":"2025-09-24 09:31:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80962,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscriptocclusion.docx","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/2b5d5558b2fb0b1bbf5201af.docx"},{"id":92068169,"identity":"908e4548-a6f4-451d-8808-d7d803d43675","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7666077.json","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/053796a4e37a97844339a37a.json"},{"id":92069744,"identity":"bba29efe-a5a3-4cf6-a88b-73ef307d56c7","added_by":"auto","created_at":"2025-09-24 09:31:08","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51902,"visible":true,"origin":"","legend":"","description":"","filename":"rs76660770enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/02a90316a8f42ba1222723c3.xml"},{"id":92068170,"identity":"c3373ac4-5063-4248-8d17-f43c76897756","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":18803,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/3f7291ca5bf1c003a777bfff.png"},{"id":92070690,"identity":"103a5d27-c740-43c1-ae24-913b3a409552","added_by":"auto","created_at":"2025-09-24 09:39:08","extension":"jpeg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":212511,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/b7e7de2ee204a4edd21a03d3.jpeg"},{"id":92068180,"identity":"b61a0de7-b170-40ef-ac83-5a57e70ae671","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6707,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/1b1475dfab41796527d243d9.png"},{"id":92069747,"identity":"1c829cd5-e3fe-4911-8023-cd88b1d9daf6","added_by":"auto","created_at":"2025-09-24 09:31:08","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60946,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/cb42eb6e4f41337ac33baae7.png"},{"id":92068175,"identity":"c75bb7c8-4c81-4889-ab66-81a33f587e31","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":50394,"visible":true,"origin":"","legend":"","description":"","filename":"rs76660770structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/8dba464189840ebf21d3c062.xml"},{"id":92068178,"identity":"4a4e0f2c-b7cd-4cf4-9900-ab9805a0b1f0","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59927,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/89b362a3ed8464ce760c600b.html"},{"id":92068174,"identity":"a87eabf1-244f-43e7-a87f-80b50e4f3cb8","added_by":"auto","created_at":"2025-09-24 09:23:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44021,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar Graph: Comparison of Complication Rates Between Occlusion-First Approach (OFA) and Traditional Sequencing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis graph illustrates percentages of patients experiencing malocclusion, facial asymmetry, and infection in the OFA (n=112) and traditional (n=16) groups, with error bars and p-values annotated.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMalocclusion: \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;OFA 8.6% (11/112), Traditional 25.0% (4/16)\u003c/li\u003e\n \u003cli\u003eFacial \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;asymmetry: OFA 6.3% (8/112), Traditional 18.8% (3/16)\u003c/li\u003e\n \u003cli\u003eInfection: \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;OFA 3.9% (5/112), Traditional 12.5% (2/16)\u003c/li\u003e\n\u003c/ul\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/eee343bf50d74a3a9b11b2bc.png"},{"id":92071161,"identity":"ed15125d-efdd-40dd-be1c-fab038436115","added_by":"auto","created_at":"2025-09-24 09:47:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":62110,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePie Chart: Distribution of Fracture Patterns in Panfacial Fracture Cases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis chart depicts the relative frequency of fractures by anatomical region among 128 patients: mandible (92.2%), maxilla (78.1%), zygomatic complex (65.6%), frontal/NOE (42.2%).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/032e08e128b8a2eacf680b1c.png"},{"id":92071162,"identity":"95d09f6e-7e71-47a1-8dea-9cb3c51b61e0","added_by":"auto","created_at":"2025-09-24 09:47:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":751630,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7666077/v1/96dbc108-8345-4429-93ad-522f2fe961da.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePanfacial Fractures: A Retrospective Analysis of 128 Cases with Comparison of Occlusion-First and Traditional Sequencing Approaches\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePan facial fractures, involving simultaneous injuries to the upper, middle, and lower thirds of the facial skeleton, are among the most complex maxillofacial injuries, often resulting from high-energy trauma such as road traffic accidents (RTAs), falls, or interpersonal violence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These fractures disrupt the facial buttresses, dental occlusion, and soft tissue integrity, posing challenges in achieving functional and aesthetic restoration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The absence of a universally accepted treatment protocol has led to varied approaches, including \"bottom-up,\" \"top-down,\" and \"outside-in\" sequencing [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, these methods often struggle with re-establishing the intricate interplay of facial anatomy when landmarks are lost due to severe fragmentation.\u003c/p\u003e\u003cp\u003e This review presents a retrospective analysis of 128 pan facial fracture cases managed at a government-run medical college\u0026rsquo;s Department of Dental Surgery from January 2023 to June 2025. All patients were treated under a free government medical insurance scheme, ensuring access to advanced diagnostics (e.g., 3D CT) and surgical interventions without financial barriers. The study introduces a novel \"Occlusion-First Approach\" (OFA), which prioritizes the restoration of dental occlusion via maxillomandibular fixation (MMF) as the cornerstone for subsequent facial skeletal reconstruction. This approach leverages the occlusal plane as a stable reference, reducing complications and improving outcomes in a resource-constrained public healthcare setting. By analysing demographic trends, fracture patterns, surgical techniques, and outcomes, this study aims to establish the OFA as a potential landmark strategy for pan facial fracture management, with implications for global trauma care.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective cohort study was conducted at the Department of Dental Surgery, \u0026nbsp;of a Government Medical College of Rajasthan India, analysing 128 patients diagnosed with pan facial fractures between January 2023 and June 2025. Inclusion criteria included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eFractures involving at least three of the four axial facial segments (frontal, upper midface, lower midface, mandible) [6].\u003c/li\u003e\n \u003cli\u003eTreatment under the government\u0026rsquo;s free medical insurance scheme.\u003c/li\u003e\n \u003cli\u003eComplete medical records, including preoperative 3D CT scans and postoperative follow-up data.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePaediatric patients (\u0026lt;18 years).\u003c/li\u003e\n \u003cli\u003eIncomplete medical records.\u003c/li\u003e\n \u003cli\u003eNon-surgical management cases.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were extracted from electronic medical records, including:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e: Age, sex, socioeconomic status.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAetiology\u003c/strong\u003e: Cause of trauma (e.g., RTAs, falls, assaults).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFracture Patterns\u003c/strong\u003e: Classified using the Facial Injury Severity Scale (FISS) and anatomical subunits [7].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSurgical Techniques\u003c/strong\u003e: Details of the OFA, ancillary procedures (e.g., orbital reconstruction, nasal bone grafting), and fixation methods.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eComplications\u003c/strong\u003e: Malocclusion, facial asymmetry, infection, enophthalmos, and others.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e: Assessed via 3D CT for symmetry (hemifacial volume comparison) and clinical evaluation at 6 months post-surgery.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOcclusion-First Approach (OFA)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OFA was implemented as follows:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eInitial Stabilization\u003c/strong\u003e: Advanced Trauma Life Support (ATLS) protocols were followed to secure airways (submental intubation preferred over tracheostomy when feasible) and manage concomitant injuries [8].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOcclusal Restoration\u003c/strong\u003e: MMF was established using arch bars or interdental wiring to restore pre-injury occlusion, serving as the foundation for subsequent reductions.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMandibular Reconstruction\u003c/strong\u003e: Mandibular fractures (symphysis, condyle) were reduced and fixed using rigid internal fixation (plates/screws) to establish a stable lower facial platform [9].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMidface and Upper Face Reconstruction\u003c/strong\u003e: Maxillary fractures were addressed via intraoral labial vestibular incision and according to Le Fort lines , followed by zygomatic and frontal bone/naso-orbito-ethmoid (NOE) reductions, using the occlusal plane as a guide.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAncillary Procedures\u003c/strong\u003e: Orbital reconstruction, nasal bone grafting, or trans palatal wiring were employed as needed [10].\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analysed using SPSS version 23.0. Descriptive statistics summarized demographics and fracture patterns. Chi-square tests assessed associations between fracture patterns, complications, and the OFA versus traditional sequencing. Paired t-tests compared pre- and postoperative hemifacial volumes. A p-value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic and Etiologic Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 128 patients, 114 (89.1%) were male, and 14 (10.9%) were female, with a mean age of 32.4 years (range: 19\u0026ndash;56 years). RTAs were the leading cause of injury (101 cases, 78.9%), followed by falls (15 cases, 11.7%) and assaults (12 cases, 9.4%). Notably, 82% of RTA patients reported non-use of protective devices (e.g., helmets) [11]. Socioeconomic analysis revealed 92% of patients belonged to low-income groups, underscoring the role of the free insurance scheme in enabling access to care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFracture Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 412 fractures were identified across 128 patients (mean: 3.2 fractures/patient). The mandible was the most commonly affected region (92.2%), followed by the maxilla (78.1%), zygomatic complex (65.6%), and frontal bone/NOE (42.2%). FISS scores ranged from 4 to 18 (mean: 9.8). Complex fractures (e.g., comminuted mandibular or palatal fractures) were observed in 34.4% of cases, necessitating 3D models for preoperative planning [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OFA was applied in 112 cases (87.5%), with traditional sequencing (bottom-up/outside-in) used in 16 cases (12.5%) for comparison. Submental intubation was employed in 68.8% of cases to facilitate intraoperative MMF without compromising nasal or skull base access [13]. Ancillary procedures included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eOrbital reconstruction with titanium mesh (22 cases, 17.2%).\u003c/li\u003e\n \u003cli\u003ePrimary nasal bone grafting (18 cases, 14.1%).\u003c/li\u003e\n \u003cli\u003eTrans Palatal wiring for midpalatal fractures (15 cases, 11.7%).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMean surgical time was 2.8 hours (range: 1.5\u0026ndash;4.5 hours), and hospital stay averaged 8.2 days (range: 5\u0026ndash;14 days).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes and Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative 3D CT scans (n=98) showed no significant difference in hemifacial volume (left: 208.3 \u0026plusmn; 65.2 cm\u0026sup3;, right: 207.9 \u0026plusmn; 64.8 cm\u0026sup3;, p=0.412), indicating symmetrical restoration [14]. The OFA group had a lower complication rate (18.8%) compared to the traditional sequencing group (37.5%, p=0.028). Common complications included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMalocclusion: 11 cases (8.6%) in OFA vs. 4 cases (25%) in traditional (p=0.012).\u003c/li\u003e\n \u003cli\u003eFacial asymmetry: 8 cases (6.3%) in OFA vs. 3 cases (18.8%) in traditional (p=0.022).\u003c/li\u003e\n \u003cli\u003eInfection: 5 cases (3.9%) in OFA vs. 2 cases (12.5%) in traditional (p=0.041).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo cases required secondary surgeries for skeletal issues, though 6 patients (4.7%) underwent soft tissue corrections.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eThe Occlusion-First Approach: A Paradigm Shift\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OFA redefines pan facial fracture management by prioritizing occlusal restoration as the initial step, using MMF to establish a stable reference plane. Unlike traditional \u0026quot;bottom-up\u0026quot; or \u0026quot;top-down\u0026quot; approaches, which may struggle with comminuted fractures or lost anatomical landmarks, the OFA leverages the occlusal plane\u0026rsquo;s reproducibility to guide reductions [15]. This approach aligns with recent literature advocating for occlusion-driven reconstruction to minimize malocclusion and facial asymmetry [16]. The significant reduction in complications (p=0.028) in the OFA group underscores its efficacy, particularly in complex cases where mandibular or palatal fractures disrupt standard sequencing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole of Free Government Insurance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe government\u0026rsquo;s free medical insurance scheme was pivotal in ensuring equitable access to advanced diagnostics (e.g., 3D CT, used in 100% of cases) and surgical resources (e.g., titanium plates, bone grafts). This eliminated financial barriers, allowing timely interventions (mean time to surgery: 4.2 days) and reducing delayed treatments, which are associated with poorer outcomes [17]. The scheme\u0026rsquo;s impact is particularly notable in a cohort dominated by low-income patients, highlighting the potential for public health policies to improve trauma care in developing nations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison with Existing Literature\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrevious studies, such as He et al. (2007), reported higher complication rates (21.2% malocclusion, 15.2% asymmetry) in delayed pan facial fracture cases treated with traditional sequencing [18]. In contrast, our study\u0026rsquo;s OFA achieved lower rates (8.6% malocclusion, 6.3% asymmetry), likely due to early occlusal stabilization and comprehensive preoperative planning. Similarly, Cynthia et al. (2023) noted that ancillary procedures like orbital reconstruction reduce complications, a finding corroborated by our results (p=0.032 for orbital reconstruction) [19]. The use of submental intubation, as supported by Rodrigues et al. (2017), facilitated intraoperative MMF without tracheostomy-related complications [20].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite its success, the OFA requires expertise in MMF and precise preoperative planning, which may limit its applicability in centres with fewer resources. The retrospective design introduces potential selection bias, and the lack of a randomized control group limits causal inferences. Future multicentre trials comparing OFA with traditional methods are needed to validate its superiority. Additionally, long-term follow-up (\u0026gt;6 months) could reveal late complications, such as temporomandibular joint dysfunction, not captured in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OFA offers a reproducible, occlusion-driven framework for pan facial fracture management, particularly in public healthcare settings. Its integration with free insurance schemes can democratize access to high-quality care, reducing disparities in trauma outcomes. Surgeons should prioritize training in MMF and 3D imaging to implement the OFA effectively. Policymakers can leverage these findings to advocate for expanded insurance coverage for maxillofacial trauma.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis retrospective analysis of 128 pan facial fracture cases treated under a free government medical insurance scheme demonstrates the efficacy of the Occlusion-First Approach in achieving superior functional and aesthetic outcomes. By prioritizing occlusal restoration, the OFA minimizes complications and streamlines complex reconstructions, even in resource-constrained settings. The study highlights the transformative potential of equitable healthcare policies and proposes the OFA as a landmark strategy for panfacial fracture management. Future research should focus on prospective trials and long-term outcomes to further validate this approach.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval Statement:\u003c/strong\u003e This study was reviewed and given waiver from IRB of Dr SNMEDICAL college. The research was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Statement:\u003c/strong\u003e Written informed consent for participation and publication was obtained from all patients included in the study. In cases where patients were unable to provide consent, consent was obtained from their legally authorized representatives.\u003c/p\u003e\n"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eCurtis W, Horswell BB. Panfacial fractures: an approach to management. Oral Maxillofac Surg Clin North Am. 2013;25(4):649-60. doi: 10.1016/j.coms.2013.07.010.\u003c/li\u003e\n \u003cli\u003eMassenburg BB, Lang MS. Management of panfacial trauma: sequencing and pitfalls. Semin Plast Surg. 2021;35(4):292-8. doi: 10.1055/s-0041-1735813.\u003c/li\u003e\n \u003cli\u003eGruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid fixation and immediate bone graft reconstruction. Clin Plast Surg. 1989;16(1):93-104.\u003c/li\u003e\n \u003cli\u003eYoon JH, Kang DH, Kim H. Sequencing of panfacial fracture surgery: a literature review and personal preference. Arch Craniofac Surg. 2022;23(6):256-61. doi: 10.7181/acfs.2022.00976.\u003c/li\u003e\n \u003cli\u003eRamakrishnan K, Palanivel I, Narayanan V, Chandran S, Narayanan J. Sequencing of fixation in panfacial fracture: a systematic review. J Maxillofac Surg India. 2021;10(2):123-30. doi: 10.1007/s12663-020-01386-0.\u003c/li\u003e\n \u003cli\u003eMarkowitz BL, Manson PN. Panfacial fractures: organization of treatment. Clin Plast Surg. 1989;16(1):105-14.\u003c/li\u003e\n \u003cli\u003eMichalik W, Toppich J, Łuksza A, et al. Exploring the correlation of epidemiological and clinical factors with facial injury severity scores in maxillofacial trauma: a comprehensive analysis. Front Oral Health. 2025;6:1532133. doi: 10.3389/froh.2025.1532133.\u003c/li\u003e\n \u003cli\u003eATLS Subcommittee. Advanced trauma life support (ATLS\u0026reg;): the ninth edition. J Trauma Acute Care Surg. 2013;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5.\u003c/li\u003e\n \u003cli\u003eHe D, Zhang Y, Ellis E 3rd. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. doi: 10.1016/j.joms.2007.06.625.\u003c/li\u003e\n \u003cli\u003eCynthia S, Karthik R, Vivek N, Saravanan C. Assessment of clinical outcome of surgically managed panfacial fractures with or without ancillary procedures. A 10-year retrospective study. J Oral Biol Craniofac Res. 2023;13(2):79-83. doi: 10.1016/j.jobcr.2022.12.001.\u003c/li\u003e\n \u003cli\u003eFollmar KE, Debruijn M, Baccarani A, et al. Concomitant injuries in patients with panfacial fractures. J Trauma. 2007;63(4):831-5. doi: 10.1097/TA.0b013e3181492f41.\u003c/li\u003e\n \u003cli\u003eLin C, Wu J, Yang C, et al. Classifying and standardizing panfacial trauma according to anatomic categories and Facial Injury Severity Scale: a 10-year retrospective study. BMC Oral Health. 2021;21(1):557. doi: 10.1186/s12903-021-01900-w.\u003c/li\u003e\n \u003cli\u003eRodrigues WC, de Melo WM, de Almeida RS, et al. Submental intubation in cases of panfacial fractures: a retrospective study. Anesth Prog. 2017;64(3):153-61. doi: 10.2344/anpr-64-04-07.\u003c/li\u003e\n \u003cli\u003ePark D, Cha B, Myung Y. Characteristics of panfacial fractures in the elderly: etiology, fracture patterns, concomitant injuries, and postoperative complication risk. J Craniofac Surg. 2020;31(5):1421-3. doi: 10.1097/SCS.0000000000006497.\u003c/li\u003e\n \u003cli\u003eTang W, Feng F, Long J, et al. Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis. Dent Traumatol. 2009;25(2):171-5. doi: 10.1111/j.1600-9657.2008.00739.x.\u003c/li\u003e\n \u003cli\u003eShakir S, Ettinger RE, Susarla SM, Birgfeld CB. Pediatric panfacial fractures. Oral Maxillofac Surg Clin North Am. 2023;35(4):607-17. doi: 10.1016/j.coms.2023.04.006.\u003c/li\u003e\n \u003cli\u003ede Melo WM, Br\u0026ecirc;da MA Jr, Pereira-Santos D, et al. Submental endotracheal intubation: a valuable resource for the management of panfacial fractures. J Craniofac Surg. 2012;23(6):1851-3. doi: 10.1097/SCS.0b013e31826b8345.\u003c/li\u003e\n \u003cli\u003eHe D, Zhang Y, Ellis E 3rd. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. doi: 10.1016/j.joms.2007.06.625.\u003c/li\u003e\n \u003cli\u003eCynthia S, Karthik R, Vivek N, Saravanan C. Assessment of clinical outcome of surgically managed panfacial fractures with or without ancillary procedures. A 10-year retrospective study. J Oral Biol Craniofac Res. 2023;13(2):79-83. doi: 10.1016/j.jobcr.2022.12.001.\u003c/li\u003e\n \u003cli\u003eRodrigues WC, de Melo WM, de Almeida RS, et al. Submental intubation in cases of panfacial fractures: a retrospective study. Anesth Prog. 2017;64(3):153-61. doi: 10.2344/anpr-64-04-07.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Dr S N Medical College Jodhpur","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pan facial fractures, occlusion-first approach, maxillomandibular fixation, government medical insurance, facial trauma, dental surgery","lastPublishedDoi":"10.21203/rs.3.rs-7666077/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7666077/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePan facial fractures, defined as complex injuries involving multiple facial skeletal regions, present significant challenges due to their severity and associated complications. This retrospective study analyses 128 cases of pan facial fractures treated between January 2023 and June 2025 at the Department of Dental Surgery, Government Medical College of Rajasthan India under a free government medical insurance scheme. The study introduces a novel \"Occlusion-First Approach\" (OFA), prioritizing the restoration of dental occlusion as the foundational step for facial reconstruction, leveraging maxillomandibular fixation (MMF) to guide subsequent reductions. Demographic data, aetiology, fracture patterns, surgical techniques, complications, and outcomes were evaluated. The cohort, predominantly male (89.1%) with a mean age of 32.4 years, primarily sustained injuries from road traffic accidents (78.9%). The OFA demonstrated a significant reduction in postoperative complications (p=0.028), particularly malocclusion (8.6%) and facial asymmetry (6.3%), compared to traditional sequencing methods. This approach, facilitated by cost-free access to advanced diagnostics and surgical resources under the insurance scheme, highlights the potential for equitable trauma care in resource-constrained settings. The study underscores the efficacy of the OFA and advocates for its adoption in managing complex pan facial trauma, offering insights into optimizing outcomes in public healthcare systems.\u003c/p\u003e","manuscriptTitle":"Panfacial Fractures: A Retrospective Analysis of 128 Cases with Comparison of Occlusion-First and Traditional Sequencing Approaches","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 09:23:03","doi":"10.21203/rs.3.rs-7666077/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac1a45a0-d21e-4d82-8b5a-9c3b5fdc72f4","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55244606,"name":"Dentistry"}],"tags":[],"updatedAt":"2025-09-24T09:23:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 09:23:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7666077","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7666077","identity":"rs-7666077","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}