上頜面中頜面骨折解剖形態(tài)綜述

1、Universal Neuro 2,1.2mm Upper-Face Module1.2mm上面部模塊,1.7mm Mid-Face Module1.7mm面中部模塊,Universal Mandible下頜通用套件,Mini-Plating System迷你接骨板系列,Universal Neuro2系列,Mini-Plating System迷你接骨板系列,Upper Face/ Mid Face上面部/面中部,,,Mi

2、dface面中部,The Midface is comprised primarily by Two Bones:面中部主要包括兩塊骨骼：The Maxilla & the Zygoma上頜骨和顴骨Maxillary fractures account for approximately 10% to 20% of all facial fractures在所有面部骨折中上頜骨骨折的發(fā)生率約為10%-20%。,Butt

3、resses支柱效應(yīng),Support pillars of the face and they transmit forces to the base of the skull.像柱子一樣支撐面部并將壓力傳導(dǎo)到頭蓋骨底部。Reconstruction of these buttresses is the key to maxillary/midfacial repair (and the general principle of

4、plate osteosynthesis)在上頜骨/面中部骨折的修復(fù)中重建這些支柱非常關(guān)鍵（這也是頜面修復(fù)接骨板應(yīng)用的普遍原則）。,Buttresses支柱效應(yīng),Vertical垂直的Pterygomaxillary (posterior)翼突上頜（后面）Zygomatico-maxillary (lateral)顴骨上頜 （側(cè)面）Nasomaxillary (medial) 鼻上頜（中間）Horizontal水平的

5、Nasofrontal (supraorbital rims)鼻骨額骨（眼眶上緣）Nasomaxillary (inferior orbital rims)鼻上頜（眼眶下壁）Inferior border of mandible下頜骨下緣,Horizontal Vertical 水平的 垂直的,Frontal Bone額骨Nasal Bo

6、nes鼻骨Ethmoid篩骨Lacrimal Bone淚骨Zygoma顴骨Maxilla上頜骨Alveolar Process牙槽突,Craniomaxillofacial (CMF) Trauma顱頜面（CFM）外傷,Direct exposure and fixation of these buttresses provides anatomical restoration.直接暴露并固定這些支柱有助于解剖結(jié)

7、構(gòu)的恢復(fù)。Main goal is to restore:修復(fù)的主要目標(biāo)：Height高度Width寬度Projection 投影,Surgical Exposure Selection術(shù)野選擇,Cosmetic appearance, inconspicuous area對外表影響較小的不明顯的區(qū)域。Avoid when possible muscles and nerves盡量避開肌肉及神經(jīng)。Sensory nerv

8、es and cranial nerves感覺神經(jīng)及顱神經(jīng)Also consider unique anatomy of patient還要考慮到患者解剖結(jié)構(gòu)的特殊性。Utilize open wounds for exposure to fracture site利用開放的傷口暴露出骨折的位置。,Exposure of the maxilla:暴露上頜骨Intraoral: vestibular incision/ Sub

9、labial/Gingivobuccal sulcus口內(nèi)入路：前庭切口/唇下/牙槽溝Periorbital:眶周入路Subciliary 睫下Transconjunctival經(jīng)結(jié)膜Subtarsal 跗骨下Infraorbital眶下Lateral brow眉弓外側(cè)Coronal冠狀Upper Eyelid/Blephoroplasty 上瞼/內(nèi)眼角,Zygoma:顴骨：Gillies Gillies入路C

10、oronal冠狀Lateral brow眉弓外側(cè)Blepharoplasty眼瞼成形術(shù)Naso-orbital-ethmoidal:鼻-眶-篩bicoronal incision 雙側(cè)冠狀切口,Upper/MidFace Surgical Approaches上面部/面中部手術(shù)入路,Coronal Approach冠狀入路,To access: Zygomatic arch, Superior, medial & l

11、ateral orbital rims, Naso ethmoidal Region, and Frontal Sinus可進(jìn)入：顴弓、眼眶前部、中間及后部、鼻篩區(qū)及額陡,Coronal Approach冠狀入路,Pericranium顱骨膜,Coronal Approach冠狀入路,Gillies Approach Gillies 入路For Closed Reduction of a Zygoma Fracture用于顴

12、骨骨折的閉合性復(fù)位,Upper Lid Blepharoplasty上眼瞼成形術(shù)入路,Zygoma Fractures, Frontozygomatic Suture Line, and Orbital Roof Fractures, Lateral brow顴骨骨折、額顴縫及眶頂骨折、眉弓外側(cè),Lateral Brow Incision眉弓外側(cè)切口,Zygoma Fractures, Frontozygomatic Suture

13、 Line, and Orbital Roof Fractures, Lateral brow顴骨骨折、額顴縫及眶頂骨折、眉弓外側(cè),Lateral Brow Incision眉弓外側(cè)切口,Transconjunctival Approach經(jīng)結(jié)膜入路,Inferior Orbital Rim, Orbital Floor, ZMC fractures, Lateral Rim, and Medial Wall前眶部、眶底、顴頜骨

14、折、眶外側(cè)壁及內(nèi)側(cè)壁,Subcilliary Approach睫下入路,Inferior Orbital Rim, Orbital Floor, ZMC fractures and Lateral Rim眶下緣、眶底、顴頜骨折、眶外側(cè),Infraorbital Incision眶下切口,Inferior Orbital Rim, Orbital Floor, ZMC fractures and Lateral Rim眶下緣、眶底

15、、顴頜骨折、眶外側(cè),Subtarsal Approach跗骨下入路,Subtarsal Approach跗骨下入路,Tarsal Plate瞼板,Periorbital Incisions眶周切口,Lateral Brow眉弓外側(cè)Upper Eyelid/Blepharplasty上瞼/瞼成形術(shù)Transconjunctival經(jīng)結(jié)膜Subciliary睫下Subtarsal跗骨下Infraorbital眶下,Vest

16、ibular/Sublabial/Gingivobuccal Sulcus Incision前庭/唇下/牙齦槽切口,Vestibular/Sublabial/Gingivobuccal Sulcus Incision前庭/唇下/牙槽溝切口,Vestibular/Sublabial/ Gingivobuccal Sulcus Incision前庭/唇下/牙槽溝切口,Universal Upperface/Midface通用上

17、面部/面中部,Zygomaticomaxillary Complex Fracture (ZMC)顴頜復(fù)合體骨折（ZMC）,Most common midface fracture!是最常見的中面骨折,,Zygoma Fracture: Surgical Approaches顴骨骨折：外科手術(shù)入路,Lateral brow incision (in or below the eyebrow) for access to the Z

18、F suture眉弓外側(cè)切口（在眉毛里或在眉毛下）達(dá)到顴骨骨折線。Vestibular incision for access to the zygomaticomaxillary buttress前庭切口可以暴露顴頜支。Subciliary, transconjunctival, subtarsal, or infraorbital for the inferior orbital rim and orbital floo

19、r睫下、經(jīng)結(jié)膜、跗骨下或眶下入路用于暴露眶下部及眶底。Gillies: Reposition of the zygoma temporally Gillies入路：可用于顴骨的臨時復(fù)位。Transbuccal (sharp hook or bone repositioning pin) 經(jīng)頰的（可應(yīng)用銳鉤或骨復(fù)位針）,ZMC Fracture: Treatment顴頜復(fù)合體骨折：治療,Exposure of the fr

20、acture sites暴露骨折位點。Reduction of the fractured bone with a sharp hook or repositioning pin用銳鉤或復(fù)位針將斷骨復(fù)位。Functionally stable plate osteosynthesis功能性穩(wěn)定的接骨術(shù),ZMC Fracture: Repositioning Pin顴頜復(fù)合體骨折：復(fù)位針,Transbuccal Stab In

21、cision經(jīng)頰針刺切口,Classification of ZMC Fractures顴頜復(fù)合體骨折的分類,Increasing displacement位移增大Occular dystopia異位Flat cheekbone cosmetic deformity顴弓變平Increased comminuting加重粉碎損傷Floor & lateral wall disruption 底部及外側(cè)壁斷裂,ZM

22、C Fracture Types顴頜復(fù)合體骨折類型,第1類,第2類,第3類,第4類,Type 1 & 2 ZMC Treatment第1類及第2類顴頜復(fù)合體骨折的治療,Reduction修復(fù)Two point fixation with rigid miniplates (1.2/1.7mm):用微型硬接骨板（1.2/1.7mm）進(jìn)行兩點固定ZF suture &Inferior orbital rim

23、顴頜縫及眶下緣,Type 3 ZMC Treatment第3類顴頜復(fù)合體骨折,Reduction 修復(fù)Wire interfragmentary alignment線性骨折Three point fixation:三點固定ZF suture顴頜縫Inferior Orbital Rim眶下緣Zygomaticomaxillary buttress 顴頜支,Type 4 ZMC Treatm

24、ent第4類顴頜復(fù)合體骨折,Reduction修復(fù)Fragment stabilization穩(wěn)定斷骨片+/- Bone grafting ± 骨移植4 point fixation:四點固定：ZF suture顴頜縫Inferior Orbital Rim眶下緣Zygomaticomaxillary buttress顴頜支Zygomatic arch顴弓,Orbital Involvemen

25、t with ZMC Fracture合并有眼眶損傷的顴頜復(fù)合體骨折,Fractures of the zygoma are always connected with fractures of the orbital floor顴骨的骨折總是伴隨著與之相連的眶底骨折,,,Fracture site骨折點,,Optical Canal視神經(jīng)管,,Zygomatic Suture顴頜縫,,Infraorbital Rim眶下緣

26、,,Infraorbital Foramen眶下孔,,Bones of the Orbit眶骨的組成,Zygoma(orange)顴弓（橙色） Nasal鼻Lacrimal(Red)淚骨（紅色） Maxilla上頜骨Frontal(Purple)額骨（紫色）Ethmoid(Gold)篩骨（金色）Sphenoid(Green)蝶骨（綠色）,Lateral Orbital rim外側(cè)壁

27、Medial orbitalRim內(nèi)側(cè)壁Medial wall內(nèi)壁Inferior orbital rim下側(cè)壁SuperiorOrbital Rim上壁Behind the eye后眼窩Behind the eye后眼窩,,,,Patient’s left eye患者的左眼,,,,,Superior View of Inferior Orbital Rim眶下壁俯視圖,Orbital Floor w

28、ith ZMC Fracture顴頜復(fù)合體復(fù)合眶下壁骨折,Fractures are reduced prior to orbital floor reconstruction將斷骨復(fù)位后再重建眶底。,Basic Orbital Floor Plate基本眶底修復(fù)板,Connection bars are anchored to infraorbital rim將連桿錨定在眶下緣。Floor plates extend ove

29、r rim plate底板要長于邊緣板。,Superior View of Anterior Orbit前眶俯視圖,Connection bars trimmed off and fixated to inner surface of orbital rim將連桿平行固定在眶緣表面。Plate covers 75% of the orbital floor 修復(fù)板要覆蓋眶底的75%。,“Blow Out” Fracture

30、“眼眶爆裂性”骨折,眶底骨折,脫垂到骨折部位的脂肪和肌肉,包埋組織,Enopthalmos- 眼球內(nèi)陷recession of the eyeball within the orbit眼球隨著眼眶一起下陷associated with ZMC/Orbital floor fractures伴隨有顴頜復(fù)合體或眶底的骨折,正常,眼球內(nèi)陷,Isolated Orbital Floor Fracture眶底離斷性骨折,Orbital

31、floor shown with fracture眶底骨折示意圖No ZMC fracture component:Orbital rim and the zygomatic complex stay intact未合并顴頜復(fù)合體骨折因素：眶緣及顴骨保持完整,,,,Isolated Orbital Floor Fracture眶底離斷性骨折,Isolated Orbital Floor Plate眶底離斷性骨折接骨板,

32、Small plate is fixated with 1.2mm screws小接骨板用1.2mm螺釘固定。Connection bars are bent up and over the infraorbital rim連桿彎曲向外越過眶下緣。,Naso-Orbital-Ethmoidal (NOE) Fracture Types鼻-眶-篩（NOE）骨折的類型,Type 1第1類single segment (latera

33、l or central fragment)單純性斷裂（側(cè)面或中間部斷裂）Type 2第2類comminuted central fragment (fractures external to medial canthal tendon insertion)中部粉碎性斷裂（骨折延伸到內(nèi)眥附著端）Type 3第3類comminuted central fragment (fractures including bone of

34、canthal tendon insertion)中部復(fù)合性斷裂（骨骼包括內(nèi)眥附著端的骨折）,Types of Midface Fractures面中部骨折的類型,Dr. Rene Le Fort studied facial fracture patternsRene Le Fort 醫(yī)生對面骨的骨折類型進(jìn)行了研究。Identified 3 lines of weakness in the facial skeleton定

35、義了3條面部骨骼最脆弱的線。These lines of weakness correspond to the sites of most frequent midfacial fractures.這些線的分布與面部骨折頻發(fā)的位置相符合。Le Fort I, Le Fort II, Le Fort III / Le Fort I、 Le Fort II、Le Fort III,LeFort Fracture Patter

36、ns LeFort骨折類型,1: LeFort I2: LeFort II3: LeFort III,上頜骨 – 從下向上骨折,LeFort I Fracture/Treatment LeFort I骨折/治療,LeFort I FractureLeFort I骨折 Results in a “floating palate”導(dǎo)致“上顎游離”。 Fracture goes through piriform aperatur

37、e and is considered bilateral骨折線穿過前鼻孔向兩側(cè)延伸。LeFort I Fracture TreatmentLeFort I骨折的治療Approaches入路Intraoral(Vestibular incision )1.口內(nèi)入路（前庭切口）MMF to reestablish the correct occlusion 利用MMF重建正常的閉合結(jié)構(gòu)。Reduction of the

38、fracture to the anatomically correct position修復(fù)斷骨重建正常解剖結(jié)構(gòu)。Functionally stable osteosynthesis by means of miniplates on the buttresses 在支柱上使用迷你型接骨板保持接骨術(shù)的功能性穩(wěn)定。Exposure of the fracture site intraorally經(jīng)口內(nèi)暴露骨折位點,,LeFor

39、t I Fracture: Placement of Mini Plates LeFort I 型骨折：迷你型接骨板的放置,Two plates on each side每側(cè)放置兩塊接骨板One straight or L-shape plate (1.7 or 2.0 mm) on the nasomaxillary buttress or piriform aperture在鼻上頜支或前鼻孔處放置一塊直型或L型接骨板(1.7

40、mm 或 2.0 mm) 。One straight or L-shape plate (1.7 or 2.0 mm) on zygomaticomaxillary buttress另一塊直型或L型接骨板(1.7 mm 或2.0 mm) 放在顴頜支上。,,,LeFort II Fracture/Treatment LeFort II 型骨折/治療,LeFort II Fracture LeFort II 型骨折LeFort I

41、I fractures result in mobility of the maxillary and nasal complexLeFort II型骨折會導(dǎo)致上頜及鼻骨的游離。Goes through zygomaticomaxillary suture (lateral orbital rim)骨折線穿過顴頜縫（眶側(cè)面）LeFort II Fracture Treatment LeFort II 型骨折的治療Approa

42、ches入路Infraorbital: subciliary or transconjunctival眶下入路：睫下或經(jīng)結(jié)膜的Intraoral (vestibular): maxilla口內(nèi)入路（前庭）上顎Coronal: nasoe thmoidal冠狀入路：經(jīng)鼻篩的MMF to reestablish the correct occlusion利用MMF來恢復(fù)正常的密閉結(jié)構(gòu) 。Reduction of the fract

43、ure in anatomically correct position恢復(fù)斷骨的正常解剖位置。Functionally stable osteosynthesis using miniplates 使用迷你型接骨板保持接骨術(shù)的功能性穩(wěn)定。,,LeFort II Fracture: Placement of Mini PlatesLeFort II 型骨折：迷你型接骨板的放置,One 1.2 or 1.7 mm pl

44、ate to stabilize the nasofrontal region鼻額區(qū)固定一塊1.2mm或1.7mm的接骨板。One 1.2 or 1.7 mm plate on the infraorbital rim 眶下緣放置一塊1.2mm或1.7mm的接骨板。One 1.7/2.0 mm plate on the nasomaxillary buttress在鼻上頜支上放置一塊1.7mm或2.0mm的接骨板。,,,,

45、One 1.7/2.0 mm plate on the zygomaticomaxillary buttress在顴上頜支上放置一塊1.7mm或2.0mm的接骨板。,LeFort III Fracture/Treatment LeFort III 型骨折/治療,LeFort III Fracture LeFort III 型骨折Le Fort III fractures result in disconnection of the

46、 face from the cranium LeFort III 型骨折會導(dǎo)致面部與頭蓋骨的離斷。Goes through nasomaxillary and nasofrontal sutures骨折線貫穿鼻額縫及鼻上頜縫LeFort III Fracture Treatment LeFort III 型骨折的治療MMF to re-establish the correct occlusion 通過MMF恢復(fù)正常的密閉

47、結(jié)構(gòu)。Reduction of the fracture in anatomically correct position恢復(fù)斷骨的正常解剖位置。Functionally stable osteosynthesis by the means of miniplates使用迷你型接骨板保持接骨術(shù)的功能性穩(wěn)定。,LeFort III ApproachesLeFort III 型骨折手術(shù)入路,Lateral brow, upper li

48、d blepharoplasty, or bicoronal眉弓外側(cè)：上瞼成形術(shù)入路或雙側(cè)冠狀切口ZF suture顴頜縫Bicoronal incision雙側(cè)冠狀切口Naso-orbital-ethmoidal fracture鼻-眶-篩骨折Subcilliary, Transconjunctival, Infraorbital Rim睫下、經(jīng)結(jié)膜、眶下緣Infrorbital rim, orbital floor眶下緣

49、、眶底Intraoral/Vestibular Incision經(jīng)口內(nèi)/前庭切口Maxilla (LeFort I fracture)上顎（LeFort I 型骨折）,LeFort III Fracture: Placement of Mini Plates LeFort III型骨折：迷你型接骨板的放置,One 1.2 mm plate to stabilize the naso-orbital-ethmoidal fracut

50、re用一塊1.2mm的接骨板穩(wěn)定鼻-眶-篩的骨折。One 1.2 or 1.7mm plate to stabilize the zygomaticofrontal suture 用一塊1.2或1.7mm的接骨板穩(wěn)定顴額縫。,,,LeFort III Fracture StabilizationLeFort III型骨折的穩(wěn)定,,Stabilization!穩(wěn)定,LeFort Osteotomies LeFort式截骨術(shù),L

51、eFort osteotomies follow the fracture lines described by LeFort.LeFort截骨術(shù)是按照LeFort提出的骨折線進(jìn)行截骨的術(shù)式。,LeFort I,LeFort III osteotomy for midface advancementLeFort III截骨術(shù)用于面中部前突的矯形。,Frontal Bone/Sinus Fractures額骨/額竇骨折,Inclu

52、des the following anatomy包括以下解剖結(jié)構(gòu)：Frontal sinus 額竇 Inner (posterior) and outer (anterior) tables內(nèi)部的（后）及外部的（前）格Nasofrontal duct鼻額管,Frontal Sinus Fracture- Anterior and Posterior Tables額竇骨折及前后格,包括鼻額管,包括鼻額管,硬脊膜撕裂和CF

53、S漏液,Clinical Example: Frontal Sinus Fracture臨床病例：額竇骨折,Treatment of Frontal Bone Fractures額骨骨折的治療,Anatomic reduction解剖位置修復(fù)Supraorbital bar contour眶上緣輪廓Orbital roof fixation 眶底固定Plates接骨板Mesh 網(wǎng)板Remove sinus septum

54、去除竇隔Obliteration for fronto-nasal duct injury解除鼻額管損傷,Pan Facial Fractures全面部骨折,Complete loss of reference points參照點全部丟失HEIGHT高度PROJECTION投影WIDTH寬度High energy/velocity injury高能/高速損傷Most all major structures/bu

55、ttresses fractured大部分主要結(jié)構(gòu)/支柱都發(fā)生骨折。,Panfacial Fractures全面部骨折,Lateral外側(cè)Zygomatic arch顴弓Lateral Orbital Rim眶外側(cè)Superior上部Frontal Bone額骨Naso-orbital-ethmoidal鼻-眶-篩Medial 中部Infraorbital rim眶下緣Maxillary buttresses 上頜

56、支Inferior下部Mandible下頜骨,Panfacial Treatment Basics全面部骨折的基礎(chǔ)治療,Good pre-operative planning良好的術(shù)前規(guī)劃accurate imaging & fracture classification精確的影像及骨折分類Restore premorbid occlusion 恢復(fù)閉合結(jié)構(gòu)MMF key to establishing bit