Download 05. Methods of conservative and operational treatment of the facial

Methods of conservative (tires,
caps) and operational
(osteosynthesis, apparatus)
treatment of the facial skull
fractures. Types of healing of the
jaws fractures. Complications of
the MFA damages: hemorrhage,
asphyxia, shock syndrome. Crush
facial tissue.
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Facial Injuries
Midface Fractures
Le-Fort Maxillary Fractures
Lower Level fractures (Le-Fort I, Transverse, Guerin)
transverse fracture separating the maxillary alveolus from the
upper mid face
Upper Level Fractures
Le-Fort II(Pyramidal fracture) : separates a pyramid-shaped
central fragment containing the maxillary dentition from the
remainder of the orbits and upper craniofacial skeleton
Le-Fort III (craniofacial dysjunction) : separates the maxilla at
the level of the upper portion of the zygoma, orbital floor, and
nasoethmoid region from the remainder of the upper
craniofacial skeleton
Le-Fort Maxillary Fractures
Maxillary Fractures
Symptoms and Signs
Periorbital hematoma
Nasopharyngeal bleeding
Pain
Swelling on the face
Intraoral lacerations
Malocclusion
Elongation of the face
Maxillary retrusion
Anterior open bite
Abnormal mobility on the dental arc
Rinorea and pneumocephaly (% 25 in LeFort II and III)
Dental Occlusion
Normal occlusion
Mandibular retrognathia
Mandibular prognathia
Bimanual maxillary examination for abnormal movement
Imaging
Plain radiographs : Waters’ and lateral view
Axial and coronal CT scans of the midface
3 D CT
Waters’ radiograph
3D CT
Coronal CT
Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji
Treatment of Maxilla Fractures
Open reduction and intermaxillary fixation and spanning
each of the butresses with plate and screws
Orbital Fractures
Classification
Orbital floor blow-out fractures
Pure (nonfractured infraorbital rim)
Inpure (fractured infraorbital rim)
Orbital fractures (without blow-out)
Lineer fractures
Combined with maxillary fractures
Zygomatic fractures
A- small orbital blow-out fracture is
confined to the orbital floor
B- larger blow-out fracture extends to
involve to the lower medial orbit as well as
orbital floor
Bone graft for repair of medial blow-out
fracture
Symptom and Signs
palpebral and subconjunctival hematoma
Diplopia (most common looking superiorly or inferiorly)
Numbness in the inferior orbital nerve
distribution
Enophthalmos
Positive forced duction test
Radiological evidence of orbital floor fracture
and entrapment of soft tissues on the CT scans
with both axial and coronal views
Assessment of the visual system is essential
Treatment of Orbital Blow-out
Fracture
There are two major surgical indications for
orbital fracture repair
Muscle entrapment (confirmed by forced duction and CT scan)
volume increase (> 2cm2 defects enophthalmos and globe
dystopia developes)
Subciliar or transconjunctival approach
Entrapped soft tissues are brought back from maxiillary
sinus
Defect are bridged with bone grafts or alloplastic
materials(silicone, titanium mesh, medpor, proplast etc.)
The Superior Orbital Fissure and Orbital
Apex Syndrome
ptosis of the eyelid
proptosis of the globe
paralysis of cranial nerve III, IV, and VI
anesthesia in the distribution of the first
division of the trigeminal nerve
If blindness occurs in combination with the
superior orbital fissure syndrome, the
condition is termed the “orbital apex
syndrome.”
Nasoethmoidal Orbital Fractures
Symptoms and signs
Telecanthus
Decrease in the dorsal nasal projection
Rinorea
Treatment:open reduction with a
combination of interfragmentary wiring and
plate and screw fixation
Nasoethmoidal Orbital Fractures
and their treatment
periorbital ecchymosis, edema, antimongoloid slant, and
subconjunctival hemorrhage.
Frontal
Worm’s-eye view.
Axial CT scan
isolated depressed left
zygomatic arch fracture.
TREATMENT
Treatment of zygomatic fracture with Gillies method
Open reduction and rigid fixation with plates and screws at
frontozygomatic suture, inferior orbital rim, and zygomaticomaxillary butress
Various types of
fractures of nasal
bones
Hematoma of Septum
Symptoms
Pain
Swelling
Respiratory obstruction
Crepitation on palpation
Nasal deformity
Deviation of the septum
Mucosal lacerations intranasally
Septal hematoma
Reduction of nasal fracture with an Asch forceps
Mandibular Fractures
the second most common facial bone injury
Mandibular fractures are classified according to
the state of the dentition (dentulous, partially
dentulous, edentulous) or the region of the
mandible in which the fracture occurs (condyle,
condylar neck, ramus, coronoid, angle, body,
symphysis)
They are classified as either open or closed,
depending on whether or not they have a
communication with a skin laceration
•subcondylar area
•angle region weakened by the
presence of the third molar
tooth
•the parasymphysis weakened
by mental foramen and canine
where the long root of the
cuspid tooth
Anatomic regions and frequency of fractures in those regions
Symptoms and Signs
Pain
Swelling
Tenderness
Malocclusion
Frequently, the patient volunteers that the teeth
do not feel like they are “coming together
properly.”
Numbness in the distribution of the mental nerve
Fractured teeth, gaps, or level discrepancies in dentition,
asymmetries of the dental arch, the presence of intraoral
lacerations, loose teeth, and crepitance indicate the possibility of
a mandibular fracture
Panorex examination of mandible
Intermaxillary fixation
Treatment of mandibular fracture by application of an arch bar and
plating at the inferior border
Osteosynthesis (internal fixation) refers to
placement of wires, screws, plates, rods,
pins & other hardware directly to the bones
to help stabilize a fracture.
Mechanical devices- wires, rods, pins,
screws and plates.
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INDICATIONS
 Trauma- facial bone fracture
 Orthognathic surgery
 Reconstruction of craniofacial deformities
 Reconstruction of bony defects 2 ͦ to ablative
tumour surgery.
 Augmentation of atrophic mandible in the
elderly
 Iatrogenic -2 ͦ to anterior/lateral
mandibulotomy
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MATERIALS
Metallic and Resorbable(biodegradable)
osteosynthetic devices.
1.Metallic
 Stainless steel
 Vitallium- trade name for alloy of
chromium, cobalt & molybdenium
 Titanium
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MATERIALS
Stainless steel-has been abandoned due to
corrosion & potential toxicity
Vitallium- used by Luhr plate system
Tensile strenght ↑ than titanium
Biocompatible but does not osteointegrate
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MATERIALS
Titanium
Ti-6Al-4V= 6% Aluminium+ 4% Vanadium
Ti-6Al-7Nb= 6% Aluminium+ 7% Niobium
Best corrosion resistance
Biocompatible
Osteointegrate
In comparison with the other materials,
offers least interference with MRI.
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BIOMECHANICS
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Biomechanics
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Biomechanics
Ideal osteosynthesis line of
mandible(Champy’s)
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Load-bearing fixation
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Load-sharing fixation
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compression plates
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Locking plate system
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INSTRUMENTATION
 Reduction forceps
Towel clip type
Bone holding clamps
Reduction/Compression forceps
 Plate holding forceps
 Screw driver ± holding sleeve (hexa, cruciform,
phillip)
 Plate benders
Bending irons
Bending pliers (flat, pronged, side bender)
 Plate cutters
 Templates
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INSTRUMENTATION
(CONTINUED)
Drilling machine
Drill bits
Drill guides (neutral or eccentric)
Depth guages
Tap
Transbuccal instruments (trocar + cannula,
guide, retractor)
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UFP
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BODY
Lag screws
One miniplate
Two plates
One large plate (recon. Plate)
3D plates
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ANGLE AND RAMUS
Single miniplate
– Oblique ridge
– Buccal surface
Two miniplates
3D plates
Reconstruction plate
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CONDYLE
Ideally, two miniplates should be applied in
a triangular fashion with one plate below
the sigmoid notch and one plate along the
posterior border.
Single DCP
Single large profile 2.0 mand plate
3D plate
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Parasymphyseal fracture
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Parasymphyseal fracture
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Angle fracture
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Defect bridging
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Primary reconstruction
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THANK YOU FOR
ATTENTION