Methods of conservative (tires, Methods of conservative (tires, caps) and operational caps) and operational

(osteosynthesis, apparatus) (osteosynthesis, apparatus) treatment of the facial skull treatment of the facial skull

fractures. Types of healing of the fractures. Types of healing of the jaws fractures. Complications of jaws fractures. Complications of the MFA damages: hemorrhage, the MFA damages: hemorrhage,

asphyxia, shock syndrome. Crush asphyxia, shock syndrome. Crush facial tissue.facial tissue.

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Facial InjuriesFacial Injuries

Lower Level fractures (Le-Fort I, Lower Level fractures (Le-Fort I, TransverseTransverse, Guerin), Guerin)transverse fracture separating the maxillary alveolus from the transverse fracture separating the maxillary alveolus from the upper mid faceupper mid face

Upper Level FracturesUpper Level FracturesLe-Fort II(Le-Fort II(Pyramidal Pyramidal fracture) : fracture) : separates a pyramid-shaped separates a pyramid-shaped central fragment containing the maxillary dentition from the central fragment containing the maxillary dentition from the remainder of the orbits and upper craniofacial skeletonremainder of the orbits and upper craniofacial skeleton

Le-Fort III (Le-Fort III (craniofacial dysjunctioncraniofacial dysjunction) : ) : separates the maxilla at separates the maxilla at the level of the upper portion of the zygoma, orbital floor, and the level of the upper portion of the zygoma, orbital floor, and nasoethmoid region from the remainder of the upper nasoethmoid region from the remainder of the upper craniofacial skeletoncraniofacial skeleton

Midface Fractures

Le-Fort Maxillary Fractures

Le-Fort Maxillary Fractures

Maxillary FracturesMaxillary FracturesSymptoms and SignsSymptoms and Signs

Periorbital hematomaPeriorbital hematomaNasopharyngeal bleedingNasopharyngeal bleedingPainPainSwelling on the faceSwelling on the faceIntraoral lacerationsIntraoral lacerationsMalocclusionMalocclusionElongation of the faceElongation of the faceMaxillary retrusionMaxillary retrusionAnterior open biteAnterior open biteAbnormal mobility on the dental arcAbnormal mobility on the dental arcRinorea and pneumocephaly (% 25 in LeFort II and III)Rinorea and pneumocephaly (% 25 in LeFort II and III)

Dental Occlusion

Normal occlusion Mandibular retrognathia Mandibular prognathia

Bimanual maxillary examination for abnormal movement

ImagingImagingPlain radiographs : Waters’ and lateral view

Axial and coronal CT scans of the midface

3 D CT

Waters’ radiograph Coronal CT3D 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 FracturesOrbital Fractures

ClassificationClassificationOrbital floor blow-out fracturesOrbital floor blow-out fractures

Pure (nonfractured infraorbital rim)Pure (nonfractured infraorbital rim)

Inpure (fractured infraorbital rim)Inpure (fractured infraorbital rim)

Orbital fractures (without blow-out)Orbital fractures (without blow-out)Lineer fracturesLineer fractures

Combined with maxillary fracturesCombined with maxillary fractures

Zygomatic fracturesZygomatic 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 Symptom and Signs

palpebral and subconjunctival hematomapalpebral and subconjunctival hematomaDiplopia (Diplopia (most common looking superiorly or inferiorlymost common looking superiorly or inferiorly))

Numbness in the inferior orbital nerve Numbness in the inferior orbital nerve distributiondistributionEnophthalmosEnophthalmosPositive forced duction testPositive forced duction testRadiological evidence of orbital floor fracture Radiological evidence of orbital floor fracture and entrapment of soft tissues on the and entrapment of soft tissues on the CT scans CT scans with both axial and coronal viewswith both axial and coronal viewsAssessment of the visual system Assessment of the visual system is essentialis essential

Treatment of Orbital Blow-out Treatment of Orbital Blow-out FractureFracture

There are two major surgical indications for There are two major surgical indications for orbital fracture repairorbital fracture repair

Muscle entrapment Muscle entrapment ((confirmed by forced duction and CT scanconfirmed by forced duction and CT scan))

volume increasevolume increase (> 2cm(> 2cm2 2 defects enophthalmos and globe defects enophthalmos and globe dystopia developes)dystopia developes)

Subciliar or transconjunctival approachSubciliar or transconjunctival approach

Entrapped soft tissues are brought back from maxiillary Entrapped soft tissues are brought back from maxiillary sinussinus

Defect are bridged with bone grafts or alloplastic Defect are bridged with bone grafts or alloplastic materials(silicone, titanium mesh, medpor, proplast etc.)materials(silicone, titanium mesh, medpor, proplast etc.)

The Superior Orbital Fissure and Orbital The Superior Orbital Fissure and Orbital Apex SyndromeApex Syndrome

ptosis of the eyelidptosis of the eyelid proptosis of the globeproptosis of the globe paralysis of cranial nerve III, IV, and VIparalysis of cranial nerve III, IV, and VI anesthesia in the distribution of the first anesthesia in the distribution of the first division of the trigeminal nervedivision of the trigeminal nerveIf blindness occurs in combination with the If blindness occurs in combination with the superior orbital fissure syndrome, the superior orbital fissure syndrome, the condition is termed the “orbital apex condition is termed the “orbital apex syndrome.”syndrome.”

Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures

Symptoms and signsSymptoms and signsTelecanthusTelecanthus

Decrease in the dorsal nasal projectionDecrease in the dorsal nasal projection

RinoreaRinorea

Treatment:Treatment:open reduction with a open reduction with a combination of interfragmentary wiring and combination of interfragmentary wiring and plate and screw fixationplate and screw fixation

Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures and their treatmentand their treatment

periorbital ecchymosis, edema, antimongoloid slant, and subconjunctival hemorrhage.

FrontalWorm’s-eye view.

Axial CT scan

isolated depressed left zygomatic arch fracture.

Treatment of zygomatic fracture with Gillies method

TREATMENT

Open reduction and rigid fixation with plates and screws at frontozygomatic suture, inferior orbital rim, and zygomatico-

maxillary butress

Various types of fractures of nasal

bones

Hematoma of Septum

SymptomsSymptoms

PainPainSwelling Swelling Respiratory obstructionRespiratory obstructionCrepitation on palpationCrepitation on palpation Nasal deformityNasal deformityDeviation of the septumDeviation of the septumMucosal lacerations intranasally Mucosal lacerations intranasally Septal hematoma Septal hematoma

Reduction of nasal fracture with an Asch forceps

Mandibular FracturesMandibular Fractures

the second most common facial bone injurythe second most common facial bone injuryMandibular fractures are classified according to Mandibular fractures are classified according to the state of the dentition (dentulous, partially the state of the dentition (dentulous, partially dentulous, edentulous) dentulous, edentulous) or or the region of the the region of the mandible in which the fracture occurs (condyle, mandible in which the fracture occurs (condyle, condylar neck, ramus, coronoid, angle, body, condylar neck, ramus, coronoid, angle, body, symphysis)symphysis)TThey are classified as either open or closed, hey are classified as either open or closed, depending on whether or not they have a depending on whether or not they have a communication with a skin lacerationcommunication with a skin laceration

Anatomic regions and frequency of fractures in those regions

•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

Symptoms and SignsSymptoms and Signs

PainPainSwellingSwellingTTendernessendernessMalocclusionMalocclusionFrequently, the patient volunteers that the teeth Frequently, the patient volunteers that the teeth do not feel like they are “coming together do not feel like they are “coming together properly.” properly.” Numbness in the distribution of the mental nerveNumbness in the distribution of the mental nerve

Fractured teeth, gaps, or level discrepancies in dentition, Fractured teeth, gaps, or level discrepancies in dentition, asymmetries of the dental arch, the presence of intraoral asymmetries of the dental arch, the presence of intraoral lacerations, loose teeth, and crepitance indicate the possibility of lacerations, loose teeth, and crepitance indicate the possibility of a mandibular fracturea mandibular fracture

Panorex examinationPanorex examination of mandible 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 Osteosynthesis (internal fixation) refers to placement of wires, screws, plates, rods, placement of wires, screws, plates, rods, pins & other hardware directly to the bones pins & other hardware directly to the bones to help stabilize a fracture. to help stabilize a fracture.

Mechanical devices- wires, rods, pins, Mechanical devices- wires, rods, pins, screws and plates.screws and plates.

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INDICATIONSINDICATIONS

Trauma- facial bone fractureTrauma- facial bone fractureOrthognathic surgeryOrthognathic surgeryReconstruction of craniofacial deformitiesReconstruction of craniofacial deformitiesReconstruction of bony defects 2 F to ablative Reconstruction of bony defects 2 F to ablative

tumour surgery.tumour surgery.Augmentation of atrophic mandible in the Augmentation of atrophic mandible in the

elderlyelderly Iatrogenic -2 F to anterior/lateral Iatrogenic -2 F to anterior/lateral

mandibulotomy mandibulotomy

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MATERIALSMATERIALS

Metallic and Resorbable(biodegradable) Metallic and Resorbable(biodegradable) osteosynthetic devices.osteosynthetic devices.

1.Metallic 1.Metallic Stainless steelStainless steelVitallium- trade name for alloy of chromium, Vitallium- trade name for alloy of chromium, cobalt & molybdeniumcobalt & molybdeniumTitanium Titanium

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MATERIALSMATERIALS

Stainless steel-has been abandoned due to Stainless steel-has been abandoned due to corrosion & potential toxicitycorrosion & potential toxicity

Vitallium- used by Luhr plate systemVitallium- used by Luhr plate system

Tensile strenght ↑ than titaniumTensile strenght ↑ than titanium

Biocompatible but does not osteointegrateBiocompatible but does not osteointegrate

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MATERIALSMATERIALS

TitaniumTitaniumTi-6Al-4V= 6% Aluminium+ 4% VanadiumTi-6Al-4V= 6% Aluminium+ 4% VanadiumTi-6Al-7Nb= 6% Aluminium+ 7% NiobiumTi-6Al-7Nb= 6% Aluminium+ 7% NiobiumBest corrosion resistanceBest corrosion resistanceBiocompatible Biocompatible OsteointegrateOsteointegrateIn comparison with the other materials, In comparison with the other materials, offers least interference with MRI.offers least interference with MRI.

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BIOMECHANICSBIOMECHANICS

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BiomechanicsBiomechanics

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BiomechanicsBiomechanics

Ideal osteosynthesis line of Ideal osteosynthesis line of mandible(Champy’s) mandible(Champy’s)

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Load-bearing fixationLoad-bearing fixation

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Load-sharing fixationLoad-sharing fixation

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compression platescompression plates

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Locking plate systemLocking plate system

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INSTRUMENTATIONINSTRUMENTATION Reduction forcepsReduction forceps

Towel clip typeTowel clip typeBone holding clampsBone holding clampsReduction/Compression forcepsReduction/Compression forceps

Plate holding forcepsPlate holding forceps Screw driver ± holding sleeve (hexa, cruciform, Screw driver ± holding sleeve (hexa, cruciform,

phillip)phillip) Plate bendersPlate benders

Bending ironsBending ironsBending pliers (flat, pronged, side bender)Bending pliers (flat, pronged, side bender)

Plate cuttersPlate cutters Templates Templates

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INSTRUMENTATION INSTRUMENTATION (CONTINUED)(CONTINUED)

Drilling machineDrilling machine

Drill bitsDrill bits

Drill guides (neutral or eccentric)Drill guides (neutral or eccentric)

Depth guagesDepth guages

Tap Tap

Transbuccal instruments (trocar + Transbuccal instruments (trocar + cannula, guide, retractor)cannula, guide, retractor)

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UFPUFP

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BODYBODY

Lag screwsLag screws

One miniplateOne miniplate

Two platesTwo plates

One large plate (recon. Plate)One large plate (recon. Plate)

3D plates3D plates

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ANGLE AND RAMUSANGLE AND RAMUS

Single miniplateSingle miniplate– Oblique ridgeOblique ridge– Buccal surfaceBuccal surface

Two miniplatesTwo miniplates

3D plates3D plates

Reconstruction plateReconstruction plate

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CONDYLECONDYLE

Ideally, two miniplates should be applied in Ideally, two miniplates should be applied in a triangular fashion with one plate below a triangular fashion with one plate below the sigmoid notch and one plate along the the sigmoid notch and one plate along the posterior border.posterior border.

Single DCPSingle DCP

Single large profile 2.0 mand plateSingle large profile 2.0 mand plate

3D plate3D plate

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Parasymphyseal fractureParasymphyseal fracture

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Parasymphyseal fractureParasymphyseal fracture

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Angle fractureAngle fracture

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Defect bridgingDefect bridging

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Primary reconstructionPrimary reconstruction

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THANK YOU FOR THANK YOU FOR ATTENTIONATTENTION