Maxillofacial Injuries
Hesham Marei
BDs, Msc, MFDS (RCS Eng), PHD.
Primary Assessment
 Air way and C-Spine Control.
 Breathing.
 Circulation.
 Disability and Neurological Examination.
...
Air way and C-spine Control
 Bleeding from oral and facial structures.
 Aspiration of foreign materials.
 Regurgitation...
Airway
 Chin lift Procedure
 Jaw Thrust procedure
 With any pt sustaining injuries above the clavicle, one should assum...
Airway
Airway
C-Spine Control
C-Spine Control
Breathing
 If the patient is breathing spontaneously
confirmed by feeling and listening for air
movement at the nostrils ...
Breathing
 Artificial ventilation should be provided with a bag
valve device connected to a mask or to an
endotracheal tu...
Breathing
 Aside from airway obstruction, the causes
of inadequate ventilation in the trauma
victim results from altered ...
Circulation
 The most common cause of shock in the traumatized patient
is hypovolemia caused by hemorrhage either externa...
How to estimate the amount of blood
Loss?????
 Pulse Rate
 Blood Pressure
 Pulse Pressure
 Capillary blanch test
 Res...
Class I (15%=750ml)
 Pulse Rate <100
 Blood Pressure normal
 Pulse Pressure normal
 Capillary blanch test normal
 Res...
Class II (750-1500ml)
15%-30%
 Pulse Rate >100
 Blood Pressure Normal
 Pulse Pressure Decreased
 Capillary blanch test...
Class III (1500-2000)
30%-40%
 Pulse Rate >120
 Blood Pressure Decreased
 Pulse Pressure Decreased
 Capillary blanch t...
Class IV (2000 or more)
40% or more
 Pulse Rate 140
 Blood Pressure Decreased
 Pulse Pressure Decreased
 Capillary bla...
Neurological Examination
(Disability)
Exposure of the Patient
 The patient should be completely disrobed
so that all of the body can be visualized,
palpated an...
Secondary Assessment
 Head and skull.
 Spinal Cord.
 Chest.
 Genitourinary.
 Abdominal.
 Extremities and fractures.
...
Fractures of the mandible
1. Epidemiology.
2. Classification of mandibular Fractures.
3. Diagnosis.
4. Access for mandibul...
Epidemiology
 Male > Female
 20 – 30 years
 Assaults, RTA, Falls, Sport injuries,
industrial injuries, Camel bite.
RTA
Assault
Assault
Classification of fracture mandible
 Fractures of any bone including the mandible can be
described in generic terms:
1. S...
Classification of fracture mandible
 Classification according to the anatomic region
involved:
1. Condylar process.
2. Co...
Classification of fracture mandible
Classification of fracture mandible
 According to the displacement of the fractured
segments:
1. Favorable.
2. Unfavorabl...
Classification of fracture mandible
Biomechanical & anatomical
considerations
Location of fracture is function of
• Place of impact
• Force of impact
• The we...
Diagnosis
 Case History.
 Clinical Examination.
 X ray Examination.
Case History
 Mechanism of Injury
 Previous facial Trauma
 Pre-injury Occlusion.
 PMH
 Last Meal
8.Gareth Wheeler
8.Gareth Wheeler
Clinical Examination
 Tenderness to Palpation.
 Malocclusion.
 Loss of Function.
 Edema.
 Altered Sensation.
 Lacera...
Malocclusion
Numbness lower lip
Hematoma
Ecchymosis
Points to remember!!!
 The maxilla, and mandible should be
evaluated for the following:
1. Avulsed teeth.
2. Presence or ...
Points to remember!!!
Radiographs
 OPT
 PA
 Lateral Oblique
 Occlusal
 CT
Case 1
Case 2
Case 3
Case 4
Treatment Plane
 Principles of Management of mandibular
Fractures:
1. Reduction.
2. Fixation.
3. Immobilization.
4. Rehab...
Reduction
 Closed Reduction.
 Open Reduction.
Closed Reduction
Pre injury Occlusion
MMF
4-6 weeks
Restoring the occlusio...
Closed Reduction
 Arch Bar.
 Eye V Loops.
 Suspension Wiring.
 Gunning Splints.
 IMF screws.
 Orthodontic Braces.
Arch Bar
Intermaxillary Fixation
Disadvantages
1.Potentially Dangerous
2.Respiratory distress
3.Reduction ventilatory flow >50%
4.P...
Cast cap Splint
Eyelet Wiring
Arch Bar
Arch Bar
Intraoperative Rigid Intermaxillary Fixation
Insertion of 4 to 6 screws and IMF
• Fast insertion and removal.
• Ideal for ...
Gunning Splints
Gunning Splints
Pt Denture
Open Reduction
 Indications:
1. Displaced unstable fracture segments
2. Associated Mid face fractures
3. Associated Condy...
Open Reduction
 Contraindication:
1. A general anesthetic or more prolonged
procedure is not advisable.
2. Sever comminut...
The Intraoral Vestibular Approach
The Intraoral Vestibular Approach
The Intraoral Marginal Rim Incision
The Intraoral Marginal Rim Incision
Extraoral Submandibular Approach
Extraoral Submandibular Approach
Retromandibular approach
Fracture management with internal
Fixation
 Wire Osteosynthesis.
 Lag Screws.
 Compression Plating.
 Miniplate Fixatio...
Fixation techniques: Wire Osteosynthesis
• Inexpensive
• Technically demanding
• Time consuming
• Risk to IANV bundle
• Po...
Steel or titanium?
• Essential is dynamic Osteosynthesis
• Titanium does not necessarily have to be removed
• Titanium is ...
Internal Fixation
 Spiessl, in 1970s applied the standards for
orthopedic surgery to mandibular fractures.
 The goals of...
DCP- EDCP
 The AO/ASIF goals require the use of
compression plate along the inferior border of the
mandible and a tension...
Fixation techniques: Compression
Osteosynthesis
•Technically difficult
• Time consuming
DCP- EDCP
• Compression Osteosynthesis.
– Rigid, “large” plates
– Extraoral approach
– Risk of nerve damage
– Difficult ad...
Principles of Lag Screw Application
Illustrations of Lag Screw Application
Miniplate
 Michelet and Champy introduced a technique that
uses transoral, malleable, non-compression bone
plates applied...
Champy principles
Advantages of this technique include:
1. Smaller incision.
2. Less soft tissue dissection.
3. Intraoral rout of applicatio...
Plating systems
 2.0mm plating system
 2.3mm plating system
 Reconstruction plate (2.4, 2.7, 3.0)
 Miniplate 0.8-1.0
...
Champy principles
Variables
• Thickness of cortex
• Osteoporosis
• Soft Cortex
• Patient factors
• diet
• bruxism
• co-mor...
Illustrations of Miniplate
Application
Mandibular angle: single plate
Illustrations of Miniplate
Application
Trans-buccal approach
Illustrations of Miniplate Application
Anterior to foramen: double plating
Illustrations of Miniplate Application
Anterior to foramen: double plating
Principles apply to the application of plates for fixation
of mandibular fractures.
 Restoration of the pre-injury occlus...
Biomechanical & anatomical
considerations
Mandibular anatomy
• Thickness of cortex
• Position roots and apices
• Position ...
Loading Sharing/ Load Bearing.
 Both the hard hare and the bone itself share the
responsibility of bearing the functional...
Multiple/comminuted and fractures with defect:
double plating
Case 1
2.JACOB OATEN (C)
2.JACOB OATEN
3.Graeme Robertson
3.Graeme Robertson
3.Graeme Robertson
3.Graeme Robertson
Case 4
5.Andrew Wheeler
5.Andrew Wheeler
5.Andrew Wheeler
5.Andrew Wheeler
Case 6
7.Kyle Inyang
7.Kyle Inyang
8.AKMOL HUSSAIN
8.AKMOL HUSSAIN
8.AKMOL HUSSAIN
8.AKMOL HUSSAIN
9.Anthony Foster-Wells
9.Anthony Foster-Wells
9.Anthony Foster-Wells
9.Anthony Foster-Wells
10.Michelle Gatheridge
10.Michelle Gatheridge
10.Michelle Gatheridge
10.Michelle Gatheridge
11.Alexander Walker
11.Alexander Walker
11.Alexander Walker
11.Alexander Walker
12.Anthony Kocus
12.Anthony Kocus
12.Anthony Kocus
12.Anthony Kocus
13.Ali Rafik
13.Ali Rafik
14.Thomas Rowlands
14.Thomas Rowlands
14.Thomas Rowlands
14.Thomas Rowlands
15.Stephen Welch
15.Stephen Welch
15.Stephen Welch
15.Stephen Welch
16.Michael Mizzi
16.Michael Mizzi
16.Michael Mizzi
16.Michael Mizzi
Non-union
Subcondylar Fractures
 Non surgical management
 Closed Reduction
 Open Reduction
Open Reduction
 Absolute Indications:
 Displacement of the condyle into the middle
cranial fossa
 Inability to achieve ...
Relative Indications
 Bilateral subcodylar Fractures.
 Associated injuries that dictate early or
immediate function.
 A...
6.NICHOLAS REES
6.NICHOLAS REES
6.NICHOLAS REES
6.NICHOLAS REES
12.GARETH MATHIAS
12.GARETH MATHIAS
12.GARETH MATHIAS
12.GARETH MATHIAS
15.THOMAS AHMED
15.THOMAS AHMED
15.THOMAS AHMED
15.THOMAS AHMED
Midface Fractures
 LeFort I Transverse Maxillary
 Lefort II Pyramidal
 Lefort III Craniofacial Dysjunction
 Zygomatic ...
Midface Fractures
 Three buttresses allow
face to absorb force
 Nasomaxillary (medial)
buttress
 Zymaticomaxillary
(lat...
Lefort Classification
 Weakest areas of midfacial complex
when assaulted from a frontal direction at
different levels (Re...
Lefort Classification
 Provides uniform method to describe the level
of major fracture lines
 Allows references regardin...
Lefort I Fracture
Transverse Maxillary
Lefort II Fracture
Pyramidal
Lefort III Fracture
Craniofacial Dysjunction
Facial Examination
 Evaluate for laceration
 Obvious depression in skull
 Asymmetry
 Discharge from nose or ear
 Assu...
Facial Examination
 Evaluate mandibular
opening
 Palpation of buccal vestibule
Crepitus of lateral antral wall
 Occlusi...
Facial Examination
 Orbits evaluated
 Periorbital edema and
ecchymosis
 Gross visual acuity
determined
 Diplopia
 Pup...
Facial Examination
Facial Examination
Orbits Evaluated
Facial Examination
Palpation of Midface/bridge of nose
Radiographic Evaluation
 Plain Films
 Lateral Skull
 Waters View
 Posteroanterior view of skull
 Submental vertex
 C...
Radiographic Evaluation
Lateral skull Water’s View
Radiographic Evaluation
CT Scan 3D CT
Radiographic Evaluation
Stereolithography
allows actual model
of defect. A nice
reconstruction tool
to use if available
Treatment of Midface Fractures
 Once patient’s condition
stabilized, no need to rush
to surgery
 Address rapidly develop...
Diagnosis of Lefort I Fractures
 Direction of force
 Maxilla displaced posteriorly
and inferiorly
 Open bite deformity
...
Treatment of Lefort I Fractures
 Direct exposure of all involved
fractures
 Reduction and anatomic
realignment of the ma...
Treatment of Lefort I Fractures
Diagnosis of Lefort II and III
 Clinical evaluation provides only a rough
impression since swelling hides the
underlying ...
Diagnosis Lefort II and III
 Bilateral periorbital
edema & ecchymosis
 Step deformity palpated
infraorbital & nasofronta...
Mid Face Fractures
 Maxilla
 Zygoma
 Orbit
 Nasoethmoidal.
5.MICHAEL DUKE
5.MICHAEL DUKE
5.MICHAEL DUKE
5.MICHAEL DUKE
L Arch.
L Arch.
Panfacial fractures
Principles of treatment
 Complete diagnosis
 Multidisciplinary approach
 Systematic approach
 Soft...
Panfacial fractures
Specific aspects
 Craniofacial skeleton: 22 bones
 Important to consider the
buttresses and maintena...
Panfacial fractures
Sequence of treatment
1. Mobilisation both jaws
2. IMF
3. Perfect anatomical reduction of mandible,
in...
Coronal flap step by step
Coronal flap step by step
Coronal flap step by step
Coronal flap step by step
Coronal flap step by step
Extra mobilisation of coronal flap
1. Periosteal incisions glabella
2. Preauricular extension
Coronal flap
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Maxillofacial injuries

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Oral & Maxillofacial Surgery
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Maxillofacial injuries

  1. 1. Maxillofacial Injuries Hesham Marei BDs, Msc, MFDS (RCS Eng), PHD.
  2. 2. Primary Assessment  Air way and C-Spine Control.  Breathing.  Circulation.  Disability and Neurological Examination.  Exposure.
  3. 3. Air way and C-spine Control  Bleeding from oral and facial structures.  Aspiration of foreign materials.  Regurgitation of stomach content.  Position of the tongue in unconscious Pt.
  4. 4. Airway  Chin lift Procedure  Jaw Thrust procedure  With any pt sustaining injuries above the clavicle, one should assume there may be cervical spine injury and should avoid hyperextension or hyper flexion of the patient neck during attempts to establish an airway. Excessive movement of the cervical spine can turn a fracture without neurological damage into a fracture that cause paralysis.  the cervical spine injury should be assumed present and should be maintained in a neutral position using backboard, sandbags, soft, semi rigid collar.  Tracheostomy.  Circocirdectomy.
  5. 5. Airway
  6. 6. Airway
  7. 7. C-Spine Control
  8. 8. C-Spine Control
  9. 9. Breathing  If the patient is breathing spontaneously confirmed by feeling and listening for air movement at the nostrils and mouth, supplemental oxygen may be delivered by face mask.  Exchange of air does not guarantee adequate ventilation.  The chest wall of a patient with a pneumothorax, flail chest, or a hemothorax may move but not ventilate effectively.  Very slow or rapid rates of respiration usually suggest poor ventilation.
  10. 10. Breathing  Artificial ventilation should be provided with a bag valve device connected to a mask or to an endotracheal tube.  The chest should be exposed and inspected for obvious injury and open wounds.  There should be equal expansion of the chest wall without intercostal and supraclavicular muscle restrictions during respiration.  The rate of breathing should be evaluated for tachypnea or abnormal breathing patterns.
  11. 11. Breathing  Aside from airway obstruction, the causes of inadequate ventilation in the trauma victim results from altered chest wall mechanics.  Open Pneumothorax.  Tension pneumothorax.  Hemothorax.  Flail Chest.
  12. 12. Circulation  The most common cause of shock in the traumatized patient is hypovolemia caused by hemorrhage either externally or internally into body cavities.  Assessment of the degree of shock is important because inadequate tissue perfusion can cause irreversible damage to vital organs, such as brain, kidneys  IV Catheters  Cross matching  FBC  U&E  LFT  Blood glucose  Blood gas analysis
  13. 13. How to estimate the amount of blood Loss?????  Pulse Rate  Blood Pressure  Pulse Pressure  Capillary blanch test  Respiratory Rate  Urine out put  Mental status  Fluid Replacement.
  14. 14. Class I (15%=750ml)  Pulse Rate <100  Blood Pressure normal  Pulse Pressure normal  Capillary blanch test normal  Respiratory Rate 14-20  Urine out put 30 or more  Mental status slightly anxious  Fluid Replacement Crystalloid
  15. 15. Class II (750-1500ml) 15%-30%  Pulse Rate >100  Blood Pressure Normal  Pulse Pressure Decreased  Capillary blanch test Positive  Respiratory Rate 20-30  Urine out put 20-30  Mental status mildly anxious  Fluid Replacement Crystalloid
  16. 16. Class III (1500-2000) 30%-40%  Pulse Rate >120  Blood Pressure Decreased  Pulse Pressure Decreased  Capillary blanch test positive  Respiratory Rate 30-40  Urine out put 5-15  Mental status Confused  Fluid Replacement Crystalloid + blood
  17. 17. Class IV (2000 or more) 40% or more  Pulse Rate 140  Blood Pressure Decreased  Pulse Pressure Decreased  Capillary blanch test positive  Respiratory Rate >35  Urine out put Nil  Mental status Confused  Fluid Replacement Crystalloid + Blood
  18. 18. Neurological Examination (Disability)
  19. 19. Exposure of the Patient  The patient should be completely disrobed so that all of the body can be visualized, palpated and examined for injuries or bleeding sites.
  20. 20. Secondary Assessment  Head and skull.  Spinal Cord.  Chest.  Genitourinary.  Abdominal.  Extremities and fractures.  Maxillofacial injuries.
  21. 21. Fractures of the mandible 1. Epidemiology. 2. Classification of mandibular Fractures. 3. Diagnosis. 4. Access for mandibular fractures. 5. Modalities of stabilization and fixation. 6. Principles of fracture Healing. 7. Sub Condylar Fractures.
  22. 22. Epidemiology  Male > Female  20 – 30 years  Assaults, RTA, Falls, Sport injuries, industrial injuries, Camel bite.
  23. 23. RTA
  24. 24. Assault
  25. 25. Assault
  26. 26. Classification of fracture mandible  Fractures of any bone including the mandible can be described in generic terms: 1. Simple or Closed Fracture. 2. Compound or open fracture. 3. Comminuted fracture. 4. Green stick Fracture. 5. Pathological Fracture. 6. Complicated Fracture. 7. Direct Fracture. 8. Indirect Fracture. 9. Impacted Fracture. 10. Incomplete Fracture.
  27. 27. Classification of fracture mandible  Classification according to the anatomic region involved: 1. Condylar process. 2. Coronoid Process. 3. Ramus. 4. Angle. 5. Body. 6. Symphsis. 7. Parasymphsis.
  28. 28. Classification of fracture mandible
  29. 29. Classification of fracture mandible  According to the displacement of the fractured segments: 1. Favorable. 2. Unfavorable. Direction of the fracture line in relation to the muscle pull. Masseter, Medial Pterygoid. Temporalis, Lateral Pterygiod. Geniohyoid, Genioglossus.
  30. 30. Classification of fracture mandible
  31. 31. Biomechanical & anatomical considerations Location of fracture is function of • Place of impact • Force of impact • The weakest zone
  32. 32. Diagnosis  Case History.  Clinical Examination.  X ray Examination.
  33. 33. Case History  Mechanism of Injury  Previous facial Trauma  Pre-injury Occlusion.  PMH  Last Meal
  34. 34. 8.Gareth Wheeler
  35. 35. 8.Gareth Wheeler
  36. 36. Clinical Examination  Tenderness to Palpation.  Malocclusion.  Loss of Function.  Edema.  Altered Sensation.  Laceration.  Bleeding, Ecchymosis, and Hematoma.
  37. 37. Malocclusion
  38. 38. Numbness lower lip
  39. 39. Hematoma
  40. 40. Ecchymosis
  41. 41. Points to remember!!!  The maxilla, and mandible should be evaluated for the following: 1. Avulsed teeth. 2. Presence or absence of teeth. 3. Type of teeth present. 4. The relationship of the teeth to the fracture line. 5. The quality of the teeth and periodontium.
  42. 42. Points to remember!!!
  43. 43. Radiographs  OPT  PA  Lateral Oblique  Occlusal  CT
  44. 44. Case 1
  45. 45. Case 2
  46. 46. Case 3
  47. 47. Case 4
  48. 48. Treatment Plane  Principles of Management of mandibular Fractures: 1. Reduction. 2. Fixation. 3. Immobilization. 4. Rehabitation.
  49. 49. Reduction  Closed Reduction.  Open Reduction. Closed Reduction Pre injury Occlusion MMF 4-6 weeks Restoring the occlusion and reducing and stabilizing the fracture segments are fundamental goals of MMF techniques.
  50. 50. Closed Reduction  Arch Bar.  Eye V Loops.  Suspension Wiring.  Gunning Splints.  IMF screws.  Orthodontic Braces.
  51. 51. Arch Bar
  52. 52. Intermaxillary Fixation Disadvantages 1.Potentially Dangerous 2.Respiratory distress 3.Reduction ventilatory flow >50% 4.Poor oral hygiene 5.Non-physiological for TMJ and 6. muscles 7.Compensating orthodontics
  53. 53. Cast cap Splint
  54. 54. Eyelet Wiring
  55. 55. Arch Bar
  56. 56. Arch Bar
  57. 57. Intraoperative Rigid Intermaxillary Fixation Insertion of 4 to 6 screws and IMF • Fast insertion and removal. • Ideal for simple fractures. • Eliminate Risk of needle stick injury.
  58. 58. Gunning Splints
  59. 59. Gunning Splints
  60. 60. Pt Denture
  61. 61. Open Reduction  Indications: 1. Displaced unstable fracture segments 2. Associated Mid face fractures 3. Associated Condylar Fractures 4. When MMF is contraindicated or not possible 5. To facilitate patient return to work.
  62. 62. Open Reduction  Contraindication: 1. A general anesthetic or more prolonged procedure is not advisable. 2. Sever comminution is present. 3. Presence of infection. 4. Patients refusing a complex treatment plane.
  63. 63. The Intraoral Vestibular Approach
  64. 64. The Intraoral Vestibular Approach
  65. 65. The Intraoral Marginal Rim Incision
  66. 66. The Intraoral Marginal Rim Incision
  67. 67. Extraoral Submandibular Approach
  68. 68. Extraoral Submandibular Approach
  69. 69. Retromandibular approach
  70. 70. Fracture management with internal Fixation  Wire Osteosynthesis.  Lag Screws.  Compression Plating.  Miniplate Fixation.  Reconstruction Plates.  Biodegradable plates.
  71. 71. Fixation techniques: Wire Osteosynthesis • Inexpensive • Technically demanding • Time consuming • Risk to IANV bundle • Potentially Insecure • Indirect Bone Healing
  72. 72. Steel or titanium? • Essential is dynamic Osteosynthesis • Titanium does not necessarily have to be removed • Titanium is more malleable • Titanium is more expensive • Identical bone healing outcome
  73. 73. Internal Fixation  Spiessl, in 1970s applied the standards for orthopedic surgery to mandibular fractures.  The goals of Spiessl and AO/ASIF were to achieve primary bone healing with normal function through four basic principles: 1. Anatomic Reduction of bone fragments. 2. Stable Internal Fixation of the fractures. 3. Preservation of blood supply. 4. Early functional mobility.
  74. 74. DCP- EDCP  The AO/ASIF goals require the use of compression plate along the inferior border of the mandible and a tension band at the alveolar level to help stabilize counteracting forces of compression and tension that act on the mandible.  Schmoker and Schilli designed an eccentric dynamic compression plate (EDCP) that achieved the concept of AO without the need for a superior tension band.
  75. 75. Fixation techniques: Compression Osteosynthesis •Technically difficult • Time consuming
  76. 76. DCP- EDCP • Compression Osteosynthesis. – Rigid, “large” plates – Extraoral approach – Risk of nerve damage – Difficult adaptation – Tapping before insertion of screws required
  77. 77. Principles of Lag Screw Application
  78. 78. Illustrations of Lag Screw Application
  79. 79. Miniplate  Michelet and Champy introduced a technique that uses transoral, malleable, non-compression bone plates applied with monocortical screws.  A class three lever will exhibit tensile forces at its upper surface and compressive forces at its lower surface when loaded.  A line of zero stress occurs when the tensile forces becomes compressive forces; this area is called the neutral zone.
  80. 80. Champy principles
  81. 81. Advantages of this technique include: 1. Smaller incision. 2. Less soft tissue dissection. 3. Intraoral rout of application. 4. Direct inspection of the occlusion during fracture reduction. 5. No scar 6. No damage to marginal mandibular branch of the facial nerve.
  82. 82. Plating systems  2.0mm plating system  2.3mm plating system  Reconstruction plate (2.4, 2.7, 3.0)  Miniplate 0.8-1.0  Microplate 0.5-0.6  Drill (1.5, 1.7)  Emergency screw.
  83. 83. Champy principles Variables • Thickness of cortex • Osteoporosis • Soft Cortex • Patient factors • diet • bruxism • co-morbidities
  84. 84. Illustrations of Miniplate Application Mandibular angle: single plate
  85. 85. Illustrations of Miniplate Application Trans-buccal approach
  86. 86. Illustrations of Miniplate Application Anterior to foramen: double plating
  87. 87. Illustrations of Miniplate Application Anterior to foramen: double plating
  88. 88. Principles apply to the application of plates for fixation of mandibular fractures.  Restoration of the pre-injury occlusion using temporary MMF.  All fracture sides should be adequately exposed and reduced before the application of any hard ware.  Loose screws must be replaced with an emergency screw.  Plates are slightly over bent to close the lingual aspect of the fracture.  Minor bone reencountering if there is irregularities on the buccal cortex.  Poor plate will cause fracture displacement during placement and tightening of the screws.  Screw holes are prepared under irrigation.  Mono-cortical Fixation.
  89. 89. Biomechanical & anatomical considerations Mandibular anatomy • Thickness of cortex • Position roots and apices • Position mandibular canal • Position mental foramen • Attachment of muscles
  90. 90. Loading Sharing/ Load Bearing.  Both the hard hare and the bone itself share the responsibility of bearing the functional load.  Fractures that are anatomically reduced have fractional resistance by the bone contact. This fraction allows the bone to contribute to fracture stability.  The load sharing between the bone and hard ware decrease the load the plate must bear.  Load Bearing: The plate only will carry the load.
  91. 91. Multiple/comminuted and fractures with defect: double plating
  92. 92. Case 1
  93. 93. 2.JACOB OATEN (C)
  94. 94. 2.JACOB OATEN
  95. 95. 3.Graeme Robertson
  96. 96. 3.Graeme Robertson
  97. 97. 3.Graeme Robertson
  98. 98. 3.Graeme Robertson
  99. 99. Case 4
  100. 100. 5.Andrew Wheeler
  101. 101. 5.Andrew Wheeler
  102. 102. 5.Andrew Wheeler
  103. 103. 5.Andrew Wheeler
  104. 104. Case 6
  105. 105. 7.Kyle Inyang
  106. 106. 7.Kyle Inyang
  107. 107. 8.AKMOL HUSSAIN
  108. 108. 8.AKMOL HUSSAIN
  109. 109. 8.AKMOL HUSSAIN
  110. 110. 8.AKMOL HUSSAIN
  111. 111. 9.Anthony Foster-Wells
  112. 112. 9.Anthony Foster-Wells
  113. 113. 9.Anthony Foster-Wells
  114. 114. 9.Anthony Foster-Wells
  115. 115. 10.Michelle Gatheridge
  116. 116. 10.Michelle Gatheridge
  117. 117. 10.Michelle Gatheridge
  118. 118. 10.Michelle Gatheridge
  119. 119. 11.Alexander Walker
  120. 120. 11.Alexander Walker
  121. 121. 11.Alexander Walker
  122. 122. 11.Alexander Walker
  123. 123. 12.Anthony Kocus
  124. 124. 12.Anthony Kocus
  125. 125. 12.Anthony Kocus
  126. 126. 12.Anthony Kocus
  127. 127. 13.Ali Rafik
  128. 128. 13.Ali Rafik
  129. 129. 14.Thomas Rowlands
  130. 130. 14.Thomas Rowlands
  131. 131. 14.Thomas Rowlands
  132. 132. 14.Thomas Rowlands
  133. 133. 15.Stephen Welch
  134. 134. 15.Stephen Welch
  135. 135. 15.Stephen Welch
  136. 136. 15.Stephen Welch
  137. 137. 16.Michael Mizzi
  138. 138. 16.Michael Mizzi
  139. 139. 16.Michael Mizzi
  140. 140. 16.Michael Mizzi
  141. 141. Non-union
  142. 142. Subcondylar Fractures  Non surgical management  Closed Reduction  Open Reduction
  143. 143. Open Reduction  Absolute Indications:  Displacement of the condyle into the middle cranial fossa  Inability to achieve occlusion with closed reduction.  Invasion of the joint space by a foreign body.
  144. 144. Relative Indications  Bilateral subcodylar Fractures.  Associated injuries that dictate early or immediate function.  Associated medical condition that dictate an open reduction.  Conditions in which treatment has been delayed an early malunion has started.
  145. 145. 6.NICHOLAS REES
  146. 146. 6.NICHOLAS REES
  147. 147. 6.NICHOLAS REES
  148. 148. 6.NICHOLAS REES
  149. 149. 12.GARETH MATHIAS
  150. 150. 12.GARETH MATHIAS
  151. 151. 12.GARETH MATHIAS
  152. 152. 12.GARETH MATHIAS
  153. 153. 15.THOMAS AHMED
  154. 154. 15.THOMAS AHMED
  155. 155. 15.THOMAS AHMED
  156. 156. 15.THOMAS AHMED
  157. 157. Midface Fractures  LeFort I Transverse Maxillary  Lefort II Pyramidal  Lefort III Craniofacial Dysjunction  Zygomatic Complex  Orbital Floor  Nasal Fractures  Naso-orbital/Ethmoid
  158. 158. Midface Fractures  Three buttresses allow face to absorb force  Nasomaxillary (medial) buttress  Zymaticomaxillary (lateral) buttress  Pyterigomaxillary (posterior) buttress
  159. 159. Lefort Classification  Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901)  Lefort I: above the level of teeth  Lefort II: at level of nasal bones  Lefort III: at orbital level
  160. 160. Lefort Classification  Provides uniform method to describe the level of major fracture lines  Allows references regarding the probable points of stability for surgical treatment  Does not incorporate vertical or segmental fractures, comminution or bone loss
  161. 161. Lefort I Fracture Transverse Maxillary
  162. 162. Lefort II Fracture Pyramidal
  163. 163. Lefort III Fracture Craniofacial Dysjunction
  164. 164. Facial Examination  Evaluate for laceration  Obvious depression in skull  Asymmetry  Discharge from nose or ear  Assume CSF leak  Palpation to note bone discontinuity  Bimanually in systematic manner
  165. 165. Facial Examination  Evaluate mandibular opening  Palpation of buccal vestibule Crepitus of lateral antral wall  Occlusion evaluated Absence and quality of dentition noted  Ecchymosis common finding  Pharynx evaluated for laceration & bleeding
  166. 166. Facial Examination  Orbits evaluated  Periorbital edema and ecchymosis  Gross visual acuity determined  Diplopia  Pupillary size & shape  Subconjunctival hemorrhage  Funduscopic evaluation
  167. 167. Facial Examination
  168. 168. Facial Examination Orbits Evaluated
  169. 169. Facial Examination Palpation of Midface/bridge of nose
  170. 170. Radiographic Evaluation  Plain Films  Lateral Skull  Waters View  Posteroanterior view of skull  Submental vertex  CT Scan  1.5 mm cuts  axial and coronal views
  171. 171. Radiographic Evaluation Lateral skull Water’s View
  172. 172. Radiographic Evaluation CT Scan 3D CT
  173. 173. Radiographic Evaluation Stereolithography allows actual model of defect. A nice reconstruction tool to use if available
  174. 174. Treatment of Midface Fractures  Once patient’s condition stabilized, no need to rush to surgery  Address rapidly developing edema  Formulate treatment plan  Observe sequelae in the case of orbital injuries
  175. 175. Diagnosis of Lefort I Fractures  Direction of force  Maxilla displaced posteriorly and inferiorly  Open bite deformity  Hypoesthesia of infraorbital nerve  Malocclusion  Mobility of maxilla  Noted by grasping maxillary incisors
  176. 176. Treatment of Lefort I Fractures  Direct exposure of all involved fractures  Reduction and anatomic realignment of the maxillary buttresses to reestablish  Anterior projection  Transverse width  Occlusion  Restoration of occlusion using IMF  Internal fixation using miniplate fixation
  177. 177. Treatment of Lefort I Fractures
  178. 178. Diagnosis of Lefort II and III  Clinical evaluation provides only a rough impression since swelling hides the underlying bony structures  Plain film radiographs and axial and coronal CT images are the basis for precise diagnosis & treatment plan
  179. 179. Diagnosis Lefort II and III  Bilateral periorbital edema & ecchymosis  Step deformity palpated infraorbital & nasofrontal area  CSF rhinorrhea  Epistaxis
  180. 180. Mid Face Fractures  Maxilla  Zygoma  Orbit  Nasoethmoidal.
  181. 181. 5.MICHAEL DUKE
  182. 182. 5.MICHAEL DUKE
  183. 183. 5.MICHAEL DUKE
  184. 184. 5.MICHAEL DUKE
  185. 185. L Arch.
  186. 186. L Arch.
  187. 187. Panfacial fractures Principles of treatment  Complete diagnosis  Multidisciplinary approach  Systematic approach  Soft tissue handling primarily  Good surgical exposure  Careful reduction  Internal fixation of fractures
  188. 188. Panfacial fractures Specific aspects  Craniofacial skeleton: 22 bones  Important to consider the buttresses and maintenance of 3D facial projection  Other bones are surrounding the facial cavities  Internal plating makes postoperative IMF superfluous
  189. 189. Panfacial fractures Sequence of treatment 1. Mobilisation both jaws 2. IMF 3. Perfect anatomical reduction of mandible, including condyles 4. Reduction & fixation of upper/ midfacial pillars 5. Reduction and fixation at midfacial (le Fort I) level, including midline split 6. Immediate grafting if required 7. Soft tissue treatment of canthus, lacrymal duct and nasal structures
  190. 190. Coronal flap step by step
  191. 191. Coronal flap step by step
  192. 192. Coronal flap step by step
  193. 193. Coronal flap step by step
  194. 194. Coronal flap step by step Extra mobilisation of coronal flap 1. Periosteal incisions glabella 2. Preauricular extension
  195. 195. Coronal flap

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