Methods of conservative and operational treatment of the facial skull fractures

Methods of conservative (tires,Methods of conservative (tires,
caps) and operationalcaps) and operational
(osteosynthesis, apparatus)(osteosynthesis, apparatus)
treatment of the facial skulltreatment of the facial skull
fractures. Types of healing of thefractures. Types of healing of the
jaws fractures. Complications ofjaws fractures. Complications of
the MFA damages: hemorrhage,the MFA damages: hemorrhage,
asphyxia, shock syndrome. Crushasphyxia, 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 thetransverse fracture separating the maxillary alveolus from the
upper mid faceupper mid face
Upper Level FracturesUpper Level Fractures
Le-Fort II(Le-Fort II(PyramidalPyramidal fracture) :fracture) : separates a pyramid-shapedseparates a pyramid-shaped
central fragment containing the maxillary dentition from thecentral 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 atseparates the maxilla at
the level of the upper portion of the zygoma, orbital floor, andthe level of the upper portion of the zygoma, orbital floor, and
nasoethmoid region from the remainder of the uppernasoethmoid region from the remainder of the upper
craniofacial skeletoncraniofacial skeleton
Midface Fractures
Le-Fort Maxillary Fractures

Maxillary FracturesMaxillary Fractures
Symptoms and SignsSymptoms and Signs
Periorbital hematomaPeriorbital hematoma
Nasopharyngeal bleedingNasopharyngeal bleeding
PainPain
Swelling on the faceSwelling on the face
Intraoral lacerationsIntraoral lacerations
MalocclusionMalocclusion
Elongation of the faceElongation of the face
Maxillary retrusionMaxillary retrusion
Anterior open biteAnterior open bite
Abnormal mobility on the dental arcAbnormal mobility on the dental arc
Rinorea 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

ImagingImaging
Plain 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
ClassificationClassification
Orbital 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 SignsSymptom and Signs
palpebral and subconjunctival hematomapalpebral and subconjunctival hematoma
Diplopia (Diplopia (most common looking superiorly or inferiorlymost common looking superiorly or inferiorly))
Numbness in the inferior orbital nerveNumbness in the inferior orbital nerve
distributiondistribution
EnophthalmosEnophthalmos
Positive forced duction testPositive forced duction test
Radiological evidence of orbital floor fractureRadiological evidence of orbital floor fracture
and entrapment of soft tissues on theand entrapment of soft tissues on the CT scansCT scans
with both axial and coronal viewswith both axial and coronal views
Assessment of the visual systemAssessment of the visual system is essentialis essential

Treatment of Orbital Blow-outTreatment of Orbital Blow-out
FractureFracture
There are two major surgical indications forThere are two major surgical indications for
orbital fracture repairorbital fracture repair
Muscle entrapmentMuscle entrapment ((confirmed by forced duction and CT scanconfirmed by forced duction and CT scan))
volume increasevolume increase (> 2cm(> 2cm22
defects enophthalmos and globedefects enophthalmos and globe
dystopia developes)dystopia developes)
Subciliar or transconjunctival approachSubciliar or transconjunctival approach
Entrapped soft tissues are brought back from maxiillaryEntrapped soft tissues are brought back from maxiillary
sinussinus
Defect are bridged with bone grafts or alloplasticDefect 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 OrbitalThe 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 firstanesthesia in the distribution of the first
division of the trigeminal nervedivision of the trigeminal nerve
If blindness occurs in combination with theIf blindness occurs in combination with the
superior orbital fissure syndrome, thesuperior orbital fissure syndrome, the
condition is termed the “orbital apexcondition is termed the “orbital apex
syndrome.”syndrome.”

Nasoethmoidal Orbital FracturesNasoethmoidal Orbital Fractures
Symptoms and signsSymptoms and signs
TelecanthusTelecanthus
Decrease in the dorsal nasal projectionDecrease in the dorsal nasal projection
RinoreaRinorea
Treatment:Treatment:open reduction with aopen reduction with a
combination of interfragmentary wiring andcombination of interfragmentary wiring and
plate and screw fixationplate and screw fixation

Nasoethmoidal Orbital FracturesNasoethmoidal Orbital Fractures
and their treatmentand 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 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

SymptomsSymptoms
PainPain
SwellingSwelling
Respiratory obstructionRespiratory obstruction
Crepitation on palpationCrepitation on palpation
Nasal deformityNasal deformity
Deviation of the septumDeviation of the septum
Mucosal lacerations intranasallyMucosal lacerations intranasally
Septal hematomaSeptal hematoma

Reduction of nasal fracture with an Asch forceps

Mandibular FracturesMandibular Fractures
the second most common facial bone injurythe second most common facial bone injury
Mandibular fractures are classified according toMandibular fractures are classified according to
the state of the dentition (dentulous, partiallythe state of the dentition (dentulous, partially
dentulous, edentulous)dentulous, edentulous) oror the region of thethe 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 adepending 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
PainPain
SwellingSwelling
TTendernessenderness
MalocclusionMalocclusion
Frequently, the patient volunteers that the teethFrequently, the patient volunteers that the teeth
do not feel like they are “coming togetherdo 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 intraoralasymmetries of the dental arch, the presence of intraoral
lacerations, loose teeth, and crepitance indicate the possibility oflacerations, loose teeth, and crepitance indicate the possibility of
a mandibular fracturea mandibular fracture

Panorex examinationPanorex examination of mandibleof mandible

Treatment of mandibular fracture by application of an arch bar and
plating at the inferior border

Osteosynthesis (internal fixation) refers toOsteosynthesis (internal fixation) refers to
placement of wires, screws, plates, rods,placement of wires, screws, plates, rods,
pins & other hardware directly to the bonespins & 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 fracture
 Orthognathic surgeryOrthognathic surgery
 Reconstruction of craniofacial deformitiesReconstruction of craniofacial deformities
 Reconstruction of bony defects 2 ͦ toReconstruction of bony defects 2 ͦ to
ablative tumour surgery.ablative tumour surgery.
 Augmentation of atrophic mandible in theAugmentation of atrophic mandible in the
elderlyelderly
 Iatrogenic -2 ͦ to anterior/lateralIatrogenic -2 ͦ to anterior/lateral
mandibulotomymandibulotomy

MATERIALSMATERIALS
Metallic and Resorbable(biodegradable)Metallic and Resorbable(biodegradable)
osteosynthetic devices.osteosynthetic devices.
1.Metallic1.Metallic
Stainless steelStainless steel
Vitallium- trade name for alloy of chromium,Vitallium- trade name for alloy of chromium,
cobalt & molybdeniumcobalt & molybdenium
TitaniumTitanium

MATERIALSMATERIALS
Stainless steel-has been abandoned due toStainless 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

MATERIALSMATERIALS
TitaniumTitanium
Ti-6Al-4V= 6% Aluminium+ 4% VanadiumTi-6Al-4V= 6% Aluminium+ 4% Vanadium
Ti-6Al-7Nb= 6% Aluminium+ 7% NiobiumTi-6Al-7Nb= 6% Aluminium+ 7% Niobium
Best corrosion resistanceBest corrosion resistance
BiocompatibleBiocompatible
OsteointegrateOsteointegrate
In comparison with the other materials,In comparison with the other materials,
offers least interference with MRI.offers least interference with MRI.

BIOMECHANICSBIOMECHANICS

BiomechanicsBiomechanics

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

Load-bearing fixationLoad-bearing fixation

Load-sharing fixationLoad-sharing fixation

compression platescompression plates

Locking plate systemLocking plate system

INSTRUMENTATIONINSTRUMENTATION
 Reduction forcepsReduction forceps
Towel clip typeTowel clip type
Bone holding clampsBone holding clamps
Reduction/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 irons
Bending pliers (flat, pronged, side bender)Bending pliers (flat, pronged, side bender)
 Plate cuttersPlate cutters
 TemplatesTemplates

INSTRUMENTATIONINSTRUMENTATION
(CONTINUED)(CONTINUED)
Drilling machineDrilling machine
Drill bitsDrill bits
Drill guides (neutral or eccentric)Drill guides (neutral or eccentric)
Depth guagesDepth guages
TapTap
Transbuccal instruments (trocar +Transbuccal instruments (trocar +
cannula, guide, retractor)cannula, guide, retractor)

UFPUFP

BODYBODY
Lag screwsLag screws
One miniplateOne miniplate
Two platesTwo plates
One large plate (recon. Plate)One large plate (recon. Plate)
3D plates3D plates

ANGLE AND RAMUSANGLE AND RAMUS
Single miniplateSingle miniplate
– Oblique ridgeOblique ridge
– Buccal surfaceBuccal surface
Two miniplatesTwo miniplates
3D plates3D plates
Reconstruction plateReconstruction plate

CONDYLECONDYLE
Ideally, two miniplates should be appliedIdeally, two miniplates should be applied
in a triangular fashion with one plate belowin a triangular fashion with one plate below
the sigmoid notch and one plate along thethe 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

Parasymphyseal fractureParasymphyseal fracture

Angle fractureAngle fracture

Defect bridgingDefect bridging

Primary reconstructionPrimary reconstruction

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Methods of conservative and operational treatment of the facial skull fractures

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Methods of conservative and operational treatment of the facial skull fractures