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  1. 1. Oral Maxillofacial Surgery Wang Yin Stomatology Department , General Hospital affiliated to Tianjin Medical University
  2. 3. <ul><li>Oral maxillofacial region includes oral cavity and maxillofacial and the cervical part. </li></ul><ul><li>It is by the frantal hairline above and the hyoid bone below. The lateral is to the posterior of the mandibular ramus. </li></ul>
  3. 4. The oral maxillofacial can be devided into 13 regions with anatomy <ul><li>1. frantal region </li></ul><ul><li>2. orbital region </li></ul><ul><li>3. infraorbital region </li></ul><ul><li>4. zygomatic region </li></ul><ul><li>5. nasal region </li></ul><ul><li>6. lips and mouth </li></ul><ul><li>7. mental branches region </li></ul><ul><li>8. buccal region </li></ul><ul><li>9. parotideomasseterical region </li></ul><ul><li>10. auricular region </li></ul><ul><li>11. temporal region </li></ul><ul><li>12. submental region </li></ul><ul><li>13. submandibular region </li></ul>
  4. 5. Oral Maxillofacial Surgery <ul><li>Diseases of Teeth and Alveolus </li></ul><ul><li>Trauma of Maxillofacial Areas </li></ul><ul><li>Cellulitis </li></ul><ul><li>Oral Maxillofacial Tumors </li></ul><ul><li>Diseases of Salivary Glands </li></ul><ul><li>Diseases of TMJ </li></ul><ul><li>Abnormality of Maxillofacial </li></ul>
  5. 6. Disease of Teeth and Alveolus
  6. 7. Dantal Implantation
  7. 8. Trauma of Maxillofacial Areas
  8. 9. Trauma of Maxillofacial Areas
  9. 10. Cellulitis ( Infection of submasseteric space)
  10. 11. Oral Maxillofacial Tumors (Fibrous Histiocytoma)
  11. 12. Diseases of Salivary Glands (Pleomorphic adenoma)
  12. 13. Diseases of TMJ
  13. 14. Abnormality of Maxillofacial
  14. 15. Orthognathic Surgery (mandibular protrusion)
  15. 16. Oral Maxillofacial Anatomy and Physiology <ul><li>Jaw </li></ul><ul><li>Muscle </li></ul><ul><li>Blood Vessel </li></ul><ul><li>Lympha System </li></ul><ul><li>Nerve </li></ul><ul><li>Salivary Gland </li></ul>
  16. 17. Jaw <ul><li>S ingle bones: </li></ul><ul><li>mandible </li></ul><ul><li>vomer </li></ul><ul><li>Symmetry bones: </li></ul><ul><li>maxilla </li></ul><ul><li>zygomatic bone </li></ul><ul><li>nasal bone </li></ul><ul><li>lacrimal bone </li></ul><ul><li>inferior nasal </li></ul><ul><li>palatine bone </li></ul>
  17. 18. Maxilla <ul><li>Maxilla is the biggest bone of the middle part of maxillofacial. It consists of a central body, which is hollowed by the maxillary sinus, and four processes. </li></ul>
  18. 19. Body of the Maxilla <ul><li>A superior or orbital surface forming the greater part of the orbital floor. </li></ul><ul><li>An anterolateral or malar surface forming the part of the skeleton of the cheek and face.( infraorbital foramen ) </li></ul><ul><li>A posterolateral or infratemporal surface turned toward the infratemporal fossa. </li></ul><ul><li>An inferior surface which, in its greater part, is covered by the alveolar process, but it is visible from within as the floor of maxillary sinus. </li></ul>
  19. 20. Maxillary Sinus
  20. 21. Maxillary Sinus
  21. 22. Maxillary Processes <ul><li>Frontal process ascending from the anteromedial corner of the body, serves for the connection with the frontal bone . </li></ul><ul><li>Zygomatic process forming the lateral corner of the body, connects with the zygomatic bone . </li></ul><ul><li>Alveolar process extending downward, carries the maxillary teeth </li></ul><ul><li>Palatine process </li></ul>
  22. 23. Palatine Process <ul><li>a horizontal process, arising from the lower edge of medial surface of the body forms, with the process of the other maxilla, the major anterior part of the skeleton of the hard palate. </li></ul>
  23. 24. Incisal Foramen <ul><li>The incisal foramen is in the front of hard palate, where nasopalatine nerve and vessels pass through. </li></ul>
  24. 25. Greater Palatine Foramen <ul><li>The major(greater) palatine foramen is in the posterior part of hard palate, where anterior palatine nerve and vessels pass though. </li></ul>
  25. 26. Fracture of Maxilla
  26. 27. Fracture of Maxilla ( Comminuted Fracture)
  27. 28. Mandible Mandible is the only one movable bone of the skull. It consists of a strong horseshoe-shaped body which continues on either side upward and backward into the mandibular ramus .
  28. 29. Mental Foramen <ul><li>In a vertical plane between the first and second bicuspid, sometimes below the second bicuspid, in rare cases below the first bicuspid, is located the mental foramen , through which the mental nerve and blood vessels emerge </li></ul>
  29. 30. Mandibular Ramus <ul><li>The ramus ends in two processes: </li></ul><ul><li>the anterior muscular coronoid process and the posterior articular condyloid process. </li></ul><ul><li>The posterior border of the ramus and the inferior border of the body meet in the mandibular angle. </li></ul>
  30. 31. Mandibular Foramen <ul><li>Almost exactly in the center of the inner surface of the mandibular ramus the mandibular canal starts with a wide opening, the mandibular foramen . The mandibular canal which houses the inferior alveolar nerve and blood vessels begins at the mandibular foramen, curves downward and forward, and turns into a horizontal course below the roots of the molars. </li></ul>
  31. 32. Fracture of Mandible <ul><li>Anterior mandible ( symphysis) </li></ul><ul><li>Body </li></ul><ul><li>Angle </li></ul><ul><li>Ramus </li></ul><ul><li>Condyle </li></ul><ul><li>Coronoid </li></ul><ul><li>Intra capsular </li></ul>30
  32. 33. Fracture of Mandible
  33. 34. Mandible <ul><li>Fewer blood stream </li></ul><ul><li>Strong muscle and fascia wrapped </li></ul><ul><li>Difficult to drain pus </li></ul><ul><li>Osteomyelitis </li></ul>
  34. 35. Muscle <ul><li>The superficial muscles of oral maxillofacial called mimetic muscles. </li></ul><ul><li>The deep muscles called masticatory muscles. </li></ul>
  35. 36. Mimetic( expression) Muscles <ul><li>Epicranius muscle </li></ul><ul><li>Procerus muscle </li></ul><ul><li>Corrugator supercilii muscle </li></ul><ul><li>Oculi muscle </li></ul><ul><li>Nasalis muscle </li></ul><ul><li>Levator labii superioris muscle </li></ul><ul><li>Zygomaticus muscle </li></ul><ul><li>Auricularis muscle </li></ul><ul><li>Levator anguli oris muscle </li></ul><ul><li>Buccinator muscle </li></ul><ul><li>Risorius muscle </li></ul><ul><li>Orbicularis oris muscle </li></ul><ul><li>Depressor anguli oris muscle </li></ul><ul><li>Depressor labi inferiors muscle </li></ul><ul><li>Platysma muscle </li></ul>
  36. 38. Mimetic( expression) Muscles <ul><li>Major function </li></ul><ul><li>Facial expression </li></ul><ul><li>Closing of the eyes </li></ul><ul><li>Closing of the lips </li></ul><ul><li>Auxiliary function </li></ul><ul><li>Intake of food </li></ul><ul><li>Mastication </li></ul><ul><li>Speaking </li></ul><ul><li>Supplied by facial nerve </li></ul>
  37. 39. Masticatory Muscles <ul><li>closing muscles </li></ul><ul><li>masseter </li></ul><ul><li>temporal </li></ul><ul><li>internal pterygoid </li></ul><ul><li>protractor </li></ul><ul><li>external pterygoid </li></ul><ul><li>opening muscles </li></ul><ul><li>digaster </li></ul><ul><li>mylohyoid </li></ul><ul><li>geniohyoid </li></ul><ul><li>Supplied by 3 rd division of trigeminal nerve </li></ul>
  38. 40. Opening Muscles
  39. 41. Opening Muscles
  40. 42. Opening Muscles
  41. 43. Lympha System <ul><li>As in all other regions of the human body, lymph vessels and lymph nodes or lymph glands of the head and neck are of great practical importance. </li></ul><ul><li>We can divide the group of lymph nodes of the head and neck into two populations: </li></ul><ul><li>circular population </li></ul><ul><li>vertical population </li></ul>
  42. 45. Circular Population <ul><li>Parotid LN submandibular or cervical LN. </li></ul><ul><li>Supermandibular LN submandibular or cervical LN. </li></ul><ul><li>Submandibular LN (collect the lymph of upper and lower teeth,lips,anterior of the nasal cavity,palate,body of tongue) </li></ul><ul><li>upper deep cervical nodes and superficial cervical nodes. </li></ul><ul><li>Submental LN submandibular or upper deep cervical LN. </li></ul>
  43. 46. Vertical Population <ul><li>Superficial cervical nodes lower deep cervical LN. </li></ul><ul><li>Upper deep cervical LN lower deep cervical nodes. </li></ul><ul><li>Inferior deep cervical LN </li></ul><ul><li>the right lymphatic trunk </li></ul><ul><li>in the right and thoracic </li></ul><ul><li>duct in the left. </li></ul>
  44. 47. Break Time E: 下载 生命的倒影 -Bridges.pps
  45. 48. Blood Vessels <ul><li>Arteries </li></ul><ul><li>The arteries of the oral cavity and the adjacent regions are, with a few exception, branches of the external carotid artery. Only parts of the nasal cavity and the upper parts of the face receive branches of the internal carotid artery. </li></ul><ul><li>The external and internal carotid arteries arise from the division of the common carotid artery. </li></ul>
  46. 49. External Carotid Artery <ul><li>Anterior Branches </li></ul><ul><li>superior thyroid artery </li></ul><ul><li>lingual artery </li></ul><ul><li>external maxillary or facial artery </li></ul><ul><li>Posterior Branches </li></ul><ul><li>occipital artery </li></ul><ul><li>auricular artery </li></ul><ul><li>Medial Branches </li></ul><ul><li>ascending pharyngeal artery </li></ul><ul><li>Terminal Branches </li></ul><ul><li>superficial temporal artery </li></ul><ul><li>internal maxillary artery </li></ul>
  47. 51. Lingual Artery <ul><li>The lingual artery arises from the external carotid artery approximately at the level of the greater horn of the hyoid bone. The numerous branches of the lingual artery supply the body and apex of the tongue. </li></ul>
  48. 53. Facial Artery <ul><li>arises from the external carotid just below the posterior belly of the digastric muscle. The branches supply </li></ul><ul><li>soft palate </li></ul><ul><li>lymph glands in the submandibular triangle </li></ul><ul><li>anterior belly of the digastric muscle </li></ul><ul><li>mylohyoid muscle </li></ul><ul><li>lips </li></ul><ul><li>lateral parts of the nose </li></ul><ul><li>adjacent part of the cheek </li></ul><ul><li>inner canthus </li></ul>
  49. 55. <ul><li>Arises from the external </li></ul><ul><li>carotid A. just below the </li></ul><ul><li>level of the mandibular </li></ul><ul><li>neck in the substance of </li></ul><ul><li>the parotid gland </li></ul>Internal Maxillary Artery
  50. 56. Internal Maxillary Artery <ul><li>Mandibular part </li></ul><ul><li>Muscular or pterygoid part </li></ul><ul><li>Maxillary part </li></ul><ul><li>Pterygopalatine part </li></ul>
  51. 57. Internal Maxillary Artery <ul><li>Mandibular part </li></ul><ul><li>(lies madial to mandibular neck) </li></ul><ul><li>middle meningeal artery </li></ul><ul><li>(for dura mater) </li></ul><ul><li>lower alveolar artery </li></ul><ul><li>(for mandible) </li></ul><ul><li>Muscular or pterygoid part </li></ul><ul><li>(in close relation to external pterygoid muscle) </li></ul><ul><li>temporal, pterygoid, masseteric, and buccinator arteries </li></ul>
  52. 58. Internal Maxillary Artery <ul><li>Maxillary part </li></ul><ul><li>( in relation to posterior surface of maxilla) </li></ul><ul><li>posterior alveolar artery </li></ul><ul><li>infraorbital artery </li></ul><ul><li>Pterygopalatine part </li></ul><ul><li>(in pterygopalatine space through sphenomaxillary gap) </li></ul><ul><li>sphenopalatine artery </li></ul><ul><li>descending palatine artery </li></ul>
  53. 59. <ul><li>The branches of the internal maxillary artery are destined for </li></ul><ul><li>deep structures of face </li></ul><ul><li>lower and upper jaw and teeth </li></ul><ul><li>masticatory muscles </li></ul><ul><li>palate </li></ul><ul><li>part of the nasal cavity </li></ul><ul><li>main supply of dura mater of the brain </li></ul>Internal Maxillary Artery
  54. 60. Superficial Temporal Artery <ul><li>Continuses of external carotid A. in the retromandibular fossa ,ascending vertically,crosses the posterior root of the zygomatic arch in front of the outer ear </li></ul>
  55. 61. Superficial Temporal Artery <ul><li>The main branches are : </li></ul><ul><li>Transverse facial artery : sends branches to the masseter muscle and parotid gland and terminates below the outer corner of the eye where it may anastomose with palpebral arteries </li></ul><ul><li>Parietal and frontal branch supply the area of the scalp </li></ul><ul><li>Zygomatico-orbital artery : send branches to the orbicularies oculi muscle. </li></ul><ul><li>Middle temporal artery : the deep branch supplys the temporal bone. </li></ul>
  56. 66. Veins
  57. 67. Superficial Vein
  58. 68. Superficial Vein Pterygoid plexus Superior ophthalmic V Lateral nasal V Angular V Submental V Deep facial V Superior labial V Inferior labial V Anterior facial V Posterior Facial V Anterior branch Common Facial V Internal Jugular V Superfacial temporal V Internal maxillary V Posterior branch Posterior Auricular V External Jugular V
  59. 69. Deep Vein
  60. 70. Deep Vein Cavernous sinus Superior ophthalmic V inferior ophthalmic V Venous plexus of foramen ovale Emissarium of lacerated foramen Angular V Anterior facial V Deep facial V Pterygoid plexus Internal maxillary V Posterior Facial V Internal nassal v Deep temporal v Maxillary branch Mandibular branch Pterygoid branch Middle meningeal v Common Facial V Internal Jugular V
  61. 71. Deep Vein <ul><li>the superficial and deep veins are united by several anastomoses </li></ul><ul><li>infection involving primarily an extracranial vein may spread to the intracranial veins and involve the meninges </li></ul><ul><li>veins of the face have few valves, the retrograde spread of infection is easy </li></ul>
  62. 72. Nerve <ul><li>Cranial Nerves </li></ul><ul><li>Trigeminal Nerve </li></ul><ul><li>Facial nerve </li></ul>
  63. 73. Cranial Nerves <ul><li>Number Name Function If injured </li></ul><ul><li>CNⅠ Olfactory Olfaction Loss the sense of smell </li></ul><ul><li>CNⅡ Optic Sight Affected sight </li></ul><ul><li>Direct light reflex missing, contralater eye: no </li></ul><ul><li>indirect light reflex </li></ul><ul><li>CNⅢ Oculomotor M.sphincter pupillae Both direct and indirect light reflex missing </li></ul><ul><li>Most extraocular muscles Eye turned outwards because of the lack of the </li></ul><ul><li>function of most of eye muscles </li></ul><ul><li>M.palpebrae sup. Ptosis </li></ul><ul><li>CNⅣ Trochlear M.oblique sup. Eye turned inwardDiplopia </li></ul><ul><li>CNⅤ Trigeminal Sensory nerve to face Diminished sensation in the skin of the face </li></ul><ul><li>Corneal reflex Missing corneal reflex </li></ul><ul><li>Masticatory muscles Diminished strength in masticatory muscles </li></ul><ul><li>CNⅥ Abducens M.rectus lateralis Eye turned inwards,reaches midline at the most </li></ul><ul><li>CNⅦ Facial Facial muscles Paralysis of mimic facial muscles </li></ul><ul><li>Partial: severed nerve Totle: cranial base injury </li></ul><ul><li>Taste in the anterior 2/3 Taste losing anterior 2/3 </li></ul><ul><li>CNⅧ Vestibulocichlear Hearing Loss of hearing </li></ul><ul><li>CNⅨ Glossopharyngeal Function of the soft palate Asymmetrical elevation of palate </li></ul><ul><li>and pharynx No gag when posterior pharynx is touched </li></ul><ul><li>CNⅩ Vagus Endotracheal suctioning does not trigger coughing </li></ul><ul><li>CNⅪ Accessory M.sternocleidomastoideus Head turned to side,ability to </li></ul><ul><li>and upper trapezius resist force decreased </li></ul><ul><li>Lift the shoulder Decreased ability to lift should </li></ul><ul><li>CNⅫ Hypoglossus tongue Atrophy,fasciculation and weakness </li></ul>
  64. 75. Trigeminal Nerve <ul><li>The motor fibers supply the masticatory muscles, that is, masseter, temporal, external and internal pterygoid muscles; also the tensor palatine muscle, the mylohyoid muscle, and the anterior belly of the digastric muscle and, in the middle ear, the tensor tympani muscle. </li></ul><ul><li>The sensory fibers arise in the large semilunar ganglion and supply the skin of the entire face and the mucous membrane of the cranial viscera with the exception of the pharynx and the base of the tongue </li></ul>
  65. 76. Ophthalmic Division <ul><li>passes through the superior orbital fissure after reaching the orbit </li></ul><ul><li>splits into nasociliary nerve frontal nerve lacrimal nerve </li></ul>
  66. 78. Maxillary Division <ul><li>leave the skull through the round foramen </li></ul><ul><li>It splits into : </li></ul><ul><li>sphenopalatine nerve </li></ul><ul><li>infraorbital nerve </li></ul><ul><li>superior alveolar nerves which supply the upper teeth, their periodontal membranes and the gingival on the outer surface of the upper jaw; </li></ul><ul><li>zygomatic nerve </li></ul>
  67. 79. Mandibular Division <ul><li>A mixed nerve and contains the entire motor portion, leaves the skull through the oval foramen and enters the infratemporal fossa. </li></ul><ul><li>The nerves for the four muscles of mastication are the masseteric nerve, posterior and anterior temporal nerve, the internal pteygoid nerve, the external pteygoid nerve </li></ul><ul><li>The four sensory branches are buccal nerve, lingual nerve, inferior alveolar nerve, the auriculotemporal nerve </li></ul>
  68. 80. Facial Nerve <ul><li>It is a mixed nerve, and has three kinds of fibers: </li></ul><ul><li>Motor fiber </li></ul><ul><li>Parasympathetic fiber </li></ul><ul><li>Taste fiber </li></ul>
  69. 81. Facial Nerve Proper <ul><li>The facial nerve proper contains the special somatic motor fibers which are destined for the muscles of facial expression, including the occipital and auricular muscles and the platysma, for the stapedius muscle, the posterior belly of the digastric, and the stylohyoid muscle. </li></ul>
  70. 82. Facial Nerve Proper At the stylomastoid foramen the main trunk of the facial nerve enters the substance of the parotid gland , the terminal branches emerge at the borders of the parotid gland. From above downward these branches are the temporal, zygomatic, buccal, mandibular and cervical branches.
  71. 83. Intermediate Nerve <ul><li>The intermediate nerve contains </li></ul><ul><li>general somatic sensory fibers which serve the deep sensibility of the face </li></ul><ul><li>special sensory fibers mediating the taste sensation in the anterior two-thirds of the tongue and on the palate. </li></ul><ul><li>preganglionic visceral efferent fibers (parasympathetic fiber) which supply the lacrimal gland, the sublingual and submaxillary salivary glands and smaller glands of oral cavity. </li></ul>
  72. 84. Salivary Glands <ul><li>parotid </li></ul><ul><li>submaxillary </li></ul><ul><li>sublingual </li></ul>
  73. 86. Parotid Gland <ul><li>It is situated in the retromandibular fossa. The outer surface of the gland is situated quite superficially, covered only by its capsule, which is by far strongest on the lateral surface of the gland, the superficial facial, and the skin. </li></ul><ul><li>The external carotid artery, posterior facial vein, the facial nerve are, for some length of their course, embedded in the substance of the parotid gland. </li></ul>
  74. 88. Parotid duct On the outer surface of the masseter muscle, emerges the parotid duct, it opens opposite the second upper molar, often at a papilla of the buccal mucosa, parotid papilla.
  75. 89. Submaxillary Gland <ul><li>round, biconvex body which occupies the inferior angle of the submaxillary triangle. </li></ul><ul><li>The duct turns to the superomedial or oral surface of mylohyoid muscle and then courses along the inner surface of the sublingual gland after crossing the lingual nerve superiorly. The duct opens at the sublingual caruncula either after uniting with the major sublingual duct or close to its opening. </li></ul><ul><li>The external maxillary artery is closely applied to the inner surface and the upper border of the maxillary gland, running in a groove of the gland. Sometimes even embedded in the glandular body itself. It sends branches into the gland and is thus tightly attached to it. </li></ul>
  76. 91. Sublingual Gland <ul><li>It is a long , flattened body situated close to the media surface of the mandible which , in this area, shows a slight depression, the sublingual fossa. </li></ul><ul><li>The greater part of the gland, forming the lateral and inferior portion of its substsnce, empties through the major sublingual duct, which either unites with the submaxillary duct or opens close to the latter at the sublingual caruncula. </li></ul>