Sequencing of Fixation in Panfacial Fracture: A Systematic Review.

Objective: In panfacial fracture management, the controversy still exists in the sequencing of fixation. The purpose of this systematic review is to establish the best sequence pattern which assists in achieving definite facial width, vertical height and anteroposterior projection.

Methods: The review was conducted according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. Two independent authors performed a comprehensive search of the PUBMED, EBSCO, J-Gate, SCOPUS and NDH for articles published up until December 2018. Sequence of fixation, timing of intervention, outcome, follow-up period and complications were evaluated for patients with panfacial fracture.

Results: In total, 202 articles were identified from the databases. After screening and full text analysis, 25 studies were included in this systematic review. Nineteen studies reported bottom-to-top sequence and two studies reported top-to-bottom approach. However, four studies reported both the approaches. The follow-up period ranges from 3 weeks to 4 years.

Conclusion: Based on the literature support and evidence, good and satisfactory outcome achieved in "Bottom-top and outside-in" sequence when compared with other sequence pattern. Early repair of panfacial fracture is advised for proper reduction and fixation, but can be delayed in accompanying life-threatening injuries. Complications are perceptible in all the sequences; it can be avoided by definitive treatment planning and stepwise management.