Comprehensive Guide to Facial Skull Fractures and Treatment Methods

1. 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.

2. 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

3. Le-Fort Maxillary Fractures

4. Maxillary FracturesSymptoms 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)

5. Dental Occlusion Normal occlusion Mandibular prognathia Mandibular retrognathia

6. Bimanual maxillary examination for abnormal movement

7. Imaging • Plain radiographs : Waters’ and lateral view • Axial and coronal CTscans of the midface • 3 D CT Coronal CT Waters’ radiograph 3D CT

8. Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji

9. Treatment of Maxilla Fractures Open reduction and intermaxillary fixation and spanning each of the butresses with plate and screws

10. 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

11. 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

13. 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

14. 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.)

15. 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.”

16. 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

18. Nasoethmoidal Orbital Fractures and their treatment

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

20. Worm’s-eye view. Frontal Axial CT scan isolated depressed left zygomatic arch fracture.

21. TREATMENT Treatment of zygomatic fracture with Gillies method

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

24. Various types of fractures of nasal bones

25. Hematoma of Septum

26. Symptoms • Pain • Swelling • Respiratory obstruction • Crepitation on palpation • Nasal deformity • Deviation of the septum • Mucosal lacerations intranasally • Septal hematoma

27. Reduction of nasal fracture with an Asch forceps

28. 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

29. subcondylar area • angle regionweakened by the presence of the third molar tooth • the parasymphysis weakenedby mental foramen and canine where the long root of the cuspid tooth Anatomic regions and frequency of fractures in those regions

30. 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

31. Panorex examination of mandible

32. Intermaxillary fixation

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

34. 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. FAMUREWA & OLADEJO

35. 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 FAMUREWA & OLADEJO

36. MATERIALS Metallic and Resorbable(biodegradable) osteosynthetic devices. 1.Metallic • Stainless steel • Vitallium- trade name for alloy of chromium, cobalt & molybdenium • Titanium FAMUREWA & OLADEJO

37. 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 FAMUREWA & OLADEJO

38. 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. FAMUREWA & OLADEJO

39. BIOMECHANICS FAMUREWA & OLADEJO

40. Biomechanics FAMUREWA & OLADEJO

41. Biomechanics Ideal osteosynthesis line of mandible(Champy’s) FAMUREWA & OLADEJO

42. FAMUREWA & OLADEJO

43. Load-bearing fixation FAMUREWA & OLADEJO

44. Load-sharing fixation FAMUREWA & OLADEJO

45. compression plates FAMUREWA & OLADEJO

46. Locking plate system FAMUREWA & OLADEJO

47. 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 FAMUREWA & OLADEJO

48. INSTRUMENTATION (CONTINUED) • Drilling machine • Drill bits • Drill guides (neutral or eccentric) • Depth guages • Tap • Transbuccal instruments (trocar + cannula, guide, retractor) FAMUREWA & OLADEJO

49. FAMUREWA & OLADEJO

50. FAMUREWA & OLADEJO