上颌面中颌面骨折解剖形态综述uppermidface课件.ppt

1、Craniomaxillofacial1.2mm Upper-Face Module1.2mm1.2mm上面部模块上面部模块1.7mm Mid-Face Module1.7mm1.7mm面中部模块面中部模块Universal Mandible下颌通用套件下颌通用套件Mini-Plating System迷你接骨板系列迷你接骨板系列Universal Neuro2系列系列Mini-Plating System迷你接骨板系列迷你接骨板系列CraniomaxillofacialUpper Face/Mid Face上面部上面部/面中部面中部CraniomaxillofacialMidface面中部面

2、中部The Midface is comprised primarily by Two Bones:面中部主要包括两块骨骼：面中部主要包括两块骨骼：The Maxilla&the Zygoma上颌骨和颧骨上颌骨和颧骨 Maxillary fractures account for approximately 10%to 20%of all facial fractures在所有面部骨折中上颌骨骨折的发生率约为10%-20%。CraniomaxillofacialButtresses支柱效应支柱效应Support pillars of the face and they transmit for

3、ces to the base of the skull.像柱子一样支撑面部并将压力传导到头盖骨底部。Reconstruction of these buttresses is the key to maxillary/midfacial repair(and the general principle of plate osteosynthesis)在上颌骨/面中部骨折的修复中重建这些支柱非常关键（这也是颌面修复接骨板应用的普遍原则）。CraniomaxillofacialButtresses支柱效应支柱效应Vertical垂直的Pterygomaxillary(posterior)翼突上颌

4、（后面）Zygomatico-maxillary(lateral)颧骨上颌（侧面）Nasomaxillary(medial)鼻上颌（中间）Horizontal水平的Nasofrontal(supraorbital rims)鼻骨额骨（眼眶上缘）Nasomaxillary(inferior orbital rims)鼻上颌（眼眶下壁）Inferior border of mandible下颌骨下缘Craniomaxillofacial Horizontal Vertical 水平的水平的 垂直的垂直的CraniomaxillofacialFrontal Bone额骨Nasal Bones鼻骨Et

5、hmoid筛骨Lacrimal Bone泪骨Zygoma颧骨Maxilla上颌骨Alveolar Process牙槽突CraniomaxillofacialCraniomaxillofacial(CMF)Trauma颅颌面（颅颌面（CFM）外伤）外伤Direct exposure and fixation of these buttresses provides anatomical restoration.直接暴露并固定这些支柱有助于解剖结构的恢复。Main goal is to restore:修复的主要目标：Height高度 Width宽度 Projection 投影Craniomaxi

6、llofacialSurgical Exposure Selection术野选择术野选择Cosmetic appearance,inconspicuous area对外表影响较小的不明显的区域。Avoid when possible muscles and nerves尽量避开肌肉及神经。Sensory nerves and cranial nerves感觉神经及颅神经Also consider unique anatomy of patient还要考虑到患者解剖结构的特殊性。Utilize open wounds for exposure to fracture site利用开放的伤口暴露出

7、骨折的位置。CraniomaxillofacialExposure of the maxilla:暴露上颌骨 Intraoral:vestibular incision/Sublabial/Gingivobuccal sulcus口内入路：前庭切口/唇下/牙槽沟 Periorbital:眶周入路 Subciliary 睫下 Transconjunctival经结膜 Subtarsal 跗骨下 Infraorbital眶下 Lateral brow眉弓外侧 Coronal冠状 Upper Eyelid/Blephoroplasty 上睑/内眼角Zygoma:颧骨：Gillies Gillies入

8、路Coronal冠状Lateral brow眉弓外侧Blepharoplasty眼睑成形术Naso-orbital-ethmoidal:鼻-眶-筛 bicoronal incision 双侧冠状切口Upper/MidFace Surgical Approaches上面部上面部/面中部手术入路面中部手术入路CraniomaxillofacialCoronal Approach冠状入路冠状入路To access:Zygomatic arch,Superior,medial&lateral orbital rims,Naso ethmoidal Region,and Frontal Sinus可进入

9、：颧弓、眼眶前部、中间及后部、鼻筛区及额陡CraniomaxillofacialCoronal Approach冠状入路冠状入路Pericranium颅骨膜CraniomaxillofacialCoronal Approach冠状入路冠状入路CraniomaxillofacialGillies Approach Gillies 入路入路For Closed Reduction of a Zygoma Fracture用于颧骨骨折的闭合性复位用于颧骨骨折的闭合性复位CraniomaxillofacialUpper Lid Blepharoplasty上眼睑成形术入路上眼睑成形术入路Zygoma

10、Fractures,Frontozygomatic Suture Line,and Orbital Roof Fractures,Lateral brow颧骨骨折、额颧缝及眶顶骨折、眉弓外侧CraniomaxillofacialLateral Brow Incision眉弓外侧切口眉弓外侧切口Zygoma Fractures,Frontozygomatic Suture Line,and Orbital Roof Fractures,Lateral brow颧骨骨折、额颧缝及眶顶骨折、眉弓外侧CraniomaxillofacialLateral Brow Incision眉弓外侧切口眉弓外侧切

11、口CraniomaxillofacialTransconjunctival Approach经结膜入路经结膜入路Inferior Orbital Rim,Orbital Floor,ZMC fractures,Lateral Rim,and Medial Wall前眶部、眶底、颧颌骨折、眶外侧壁及内侧壁CraniomaxillofacialSubcilliary Approach睫下入路睫下入路Inferior Orbital Rim,Orbital Floor,ZMC fractures and Lateral Rim眶下缘、眶底、颧颌骨折、眶外侧CraniomaxillofacialInf

12、raorbital Incision眶下切口眶下切口Inferior Orbital Rim,Orbital Floor,ZMC fractures and Lateral Rim眶下缘、眶底、颧颌骨折、眶外侧Craniomaxillofacial Subtarsal Approach跗骨下入路跗骨下入路Craniomaxillofacial Subtarsal Approach跗骨下入路跗骨下入路Tarsal Plate睑板Craniomaxillofacial Periorbital Incisions眶周切口眶周切口Lateral Brow眉弓外侧Upper Eyelid/Blephar

13、plasty上睑/睑成形术Transconjunctival经结膜Subciliary睫下Subtarsal跗骨下Infraorbital眶下CraniomaxillofacialVestibular/Sublabial/Gingivobuccal Sulcus Incision前庭前庭/唇下唇下/牙龈槽切口牙龈槽切口CraniomaxillofacialVestibular/Sublabial/Gingivobuccal Sulcus Incision前庭前庭/唇下唇下/牙槽沟切口牙槽沟切口CraniomaxillofacialVestibular/Sublabial/Gingivobucc

14、al Sulcus Incision前庭前庭/唇下唇下/牙槽沟切口牙槽沟切口CraniomaxillofacialUniversal Upperface/Midface通用上面部通用上面部/面中部面中部CraniomaxillofacialZygomaticomaxillary Complex Fracture(ZMC)颧颌复合体骨折（颧颌复合体骨折（ZMC）Most common midface fracture!是最常见的中面骨折CraniomaxillofacialZygoma Fracture:Surgical Approaches颧骨骨折：外科手术入路颧骨骨折：外科手术入路 Late

15、ral brow incision(in or below the eyebrow)for access to the ZF suture 眉弓外侧切口（在眉毛里或在眉毛下）达到颧骨骨折线。Vestibular incision for access to the zygomaticomaxillary buttress 前庭切口可以暴露颧颌支。Subciliary,transconjunctival,subtarsal,or infraorbital for the inferior orbital rim and orbital floor 睫下、经结膜、跗骨下或眶下入路用于暴露眶下部及眶

16、底。Gillies:Reposition of the zygoma temporally Gillies入路：可用于颧骨的临时复位。Transbuccal(sharp hook or bone repositioning pin)经颊的（可应用锐钩或骨复位针）CraniomaxillofacialZMC Fracture:Treatment颧颌复合体骨折：治疗颧颌复合体骨折：治疗Exposure of the fracture sites暴露骨折位点。Reduction of the fractured bone with a sharp hook or repositioning pin用

17、锐钩或复位针将断骨复位。Functionally stable plate osteosynthesis功能性稳定的接骨术CraniomaxillofacialZMC Fracture:Repositioning Pin颧颌复合体骨折：复位针颧颌复合体骨折：复位针Transbuccal Stab Incision经颊针刺切口CraniomaxillofacialClassification of ZMC Fractures颧颌复合体骨折的分类颧颌复合体骨折的分类Increasing displacement位移位移增大增大 Occular dystopia异位 Flat cheekbone c

18、osmetic deformity颧弓变平Increased comminuting加重粉碎损伤加重粉碎损伤 Floor&lateral wall disruption 底部及外侧壁断裂CraniomaxillofacialZMC Fracture Types颧颌复合体骨折类型颧颌复合体骨折类型第1类第2类第3类第4类CraniomaxillofacialType 1&2 ZMC Treatment第第1类及第类及第2类颧颌复合体骨折的治疗类颧颌复合体骨折的治疗Reduction修复修复Two point fixation with rigid miniplates(1.2/1.7mm):用微

19、型硬接骨板（用微型硬接骨板（1.2/1.7mm）进行）进行两点固定两点固定ZF suture&Inferior orbital rim颧颌缝及眶下缘颧颌缝及眶下缘CraniomaxillofacialType 3 ZMC Treatment第第3类颧颌复合体骨折类颧颌复合体骨折Reduction 修复修复Wire interfragmentary alignment线性骨折线性骨折Three point fixation:三点固定三点固定ZF suture颧颌缝颧颌缝Inferior Orbital Rim眶下缘眶下缘Zygomaticomaxillary buttress 颧颌支颧颌支Cra

20、niomaxillofacialType 4 ZMC Treatment第第4类颧颌复合体骨折类颧颌复合体骨折Reduction修复修复Fragment stabilization稳定稳定断骨片断骨片+/-Bone grafting 骨移植骨移植4 point fixation:四点四点固定：固定：ZF suture颧颌缝颧颌缝Inferior Orbital Rim眶下缘眶下缘Zygomaticomaxillary buttress颧颌支颧颌支Zygomatic arch颧弓颧弓CraniomaxillofacialOrbital Involvement with ZMC Fracture合

21、并有眼眶损伤的颧颌复合体骨折合并有眼眶损伤的颧颌复合体骨折Fractures of the zygoma are always connected with fractures of the orbital floor颧骨的骨折总是伴随着与之相连的眶底骨折颧骨的骨折总是伴随着与之相连的眶底骨折Fracture site骨折点Optical Canal视神经管视神经管Zygomatic Suture颧颌缝颧颌缝Infraorbital Rim眶下缘眶下缘Infraorbital Foramen眶下孔眶下孔CraniomaxillofacialBones of the Orbit眶骨的组成眶骨的组

22、成Zygoma(orange)颧弓（橙色）Nasal鼻Lacrimal(Red)泪骨（红色）Maxilla上颌骨Frontal(Purple)额骨（紫色）Ethmoid(Gold)筛骨（金色）Sphenoid(Green)蝶骨（绿色）Lateral Orbital rim外侧壁Medial orbitalRim内侧壁Medial wall内壁Inferior orbital rim下侧壁SuperiorOrbital Rim上壁Behind the eye后眼窝Behind the eye后眼窝Patients left eye患者的左眼患者的左眼CraniomaxillofacialSupe

23、rior View of Inferior Orbital Rim眶下壁俯视图CraniomaxillofacialOrbital Floor with ZMC Fracture颧颌复合体复合眶下壁骨折颧颌复合体复合眶下壁骨折Fractures are reduced prior to orbital floor reconstruction将断骨复位后再重建眶底。CraniomaxillofacialBasic Orbital Floor Plate基本眶底修复板基本眶底修复板Connection bars are anchored to infraorbital rim将连杆锚定在眶下缘。

24、Floor plates extend over rim plate底板要长于边缘板。CraniomaxillofacialSuperior View of Anterior Orbit前眶俯视图前眶俯视图Connection bars trimmed off and fixated to inner surface of orbital rim将连杆平行固定在眶缘表面。Plate covers 75%of the orbital floor 修复板要覆盖眶底的75%。Craniomaxillofacial“Blow Out”Fracture“眼眶爆裂性眼眶爆裂性”骨折骨折眶底骨折脱垂到骨折部

25、位的脂肪和肌肉包埋组织CraniomaxillofacialEnopthalmos-眼球内陷眼球内陷 recession of the eyeball within the orbit眼球随着眼眶一起下陷眼球随着眼眶一起下陷 associated with ZMC/Orbital floor fractures伴随有颧颌复合体或伴随有颧颌复合体或眶底的骨折眶底的骨折正常眼球内陷CraniomaxillofacialIsolated Orbital Floor Fracture眶底离断性骨折眶底离断性骨折Orbital floor shown with fracture眶底骨折示意图No ZMC

26、 fracture component:Orbital rim and the zygomatic complex stay intact未合并颧颌复合体骨折因素：眶缘及颧骨保持完整CraniomaxillofacialIsolated Orbital Floor Fracture眶底离断性骨折眶底离断性骨折CraniomaxillofacialIsolated Orbital Floor Plate眶底离断性骨折接骨板眶底离断性骨折接骨板Small plate is fixated with 1.2mm screws小接骨板用1.2mm螺钉固定。Connection bars are ben

27、t up and over the infraorbital rim连杆弯曲向外越过眶下缘。CraniomaxillofacialNaso-Orbital-Ethmoidal(NOE)Fracture Types鼻鼻-眶眶-筛（筛（NOE）骨折的类型）骨折的类型Type 1第第1类类single segment(lateral or central fragment)单纯性断裂（侧面或中间部断裂）单纯性断裂（侧面或中间部断裂）Type 2第第2类类comminuted central fragment(fractures external to medial canthal tendon in

28、sertion)中部粉碎性断裂（骨折延伸到内中部粉碎性断裂（骨折延伸到内眦眦附着端）附着端）Type 3第第3类类comminuted central fragment(fractures including bone of canthal tendon insertion)中部复合性断裂（骨骼包括内中部复合性断裂（骨骼包括内眦附着端的骨折眦附着端的骨折）CraniomaxillofacialTypes of Midface Fractures面中部骨折的类型面中部骨折的类型Dr.Rene Le Fort studied facial fracture patternsRene Le Fort

29、 医生对面骨的骨折类型进行了研究。医生对面骨的骨折类型进行了研究。Identified 3 lines of weakness in the facial skeleton 定义了3条面部骨骼最脆弱的线。These lines of weakness correspond to the sites of most frequent midfacial fractures.这些线的分布与面部骨折频发的位置相符合。Le Fort I,Le Fort II,Le Fort III/Le Fort I、Le Fort II、Le Fort IIICraniomaxillofacialLeFort Fr

30、acture Patterns LeFort骨折类型骨折类型上颌骨 从下向上骨折CraniomaxillofacialLeFort I Fracture/Treatment LeFort I骨折骨折/治疗治疗LeFort I FractureLeFort I骨折骨折 Results in a“floating palate”导致“上颚游离”。Fracture goes through piriform aperature and is considered bilateral骨折线穿过前鼻孔向两侧延伸。LeFort I Fracture TreatmentLeFort I骨折的治疗骨折的治疗A

31、pproaches入路1.Intraoral(Vestibular incision)1.口内入路（前庭切口）MMF to reestablish the correct occlusion 利用MMF重建正常的闭合结构。Reduction of the fracture to the anatomically correct position修复断骨重建正常解剖结构。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术的功能性稳定。Exposure of th

32、e fracture site intraorally经口内暴露骨折位点CraniomaxillofacialLeFort I Fracture:Placement of Mini Plates LeFort I 型骨折：迷你型接骨板的放置型骨折：迷你型接骨板的放置Two plates on each side每侧放置两块接骨板每侧放置两块接骨板One straight or L-shape plate(1.7 or 2.0 mm)on the nasomaxillary buttress or piriform aperture在鼻上颌支或前鼻孔处放置一块直型或L型接骨板(1.7 mm 或

33、2.0 mm)。One straight or L-shape plate(1.7 or 2.0 mm)on zygomaticomaxillary buttress另一块直型或L型接骨板(1.7 mm 或2.0 mm)放在颧颌支上。CraniomaxillofacialLeFort II Fracture/Treatment LeFort II 型骨折型骨折/治疗治疗LeFort II Fracture LeFort II 型骨折LeFort II fractures result in mobility of the maxillary and nasal complexLeFort II

34、型骨折会导致上颌及鼻骨的游离。Goes through zygomaticomaxillary suture(lateral orbital rim)骨折线穿过颧颌缝（眶侧面）LeFort II Fracture Treatment LeFort II 型骨折的治疗Approaches入路1.Infraorbital:subciliary or transconjunctival眶下入路：睫下或经结膜的2.Intraoral(vestibular):maxilla口内入路（前庭）上颚3.Coronal:nasoe thmoidal冠状入路：经鼻筛的MMF to reestablish the

35、correct occlusion利用MMF来恢复正常的密闭结构。Reduction of the fracture in anatomically correct position恢复断骨的正常解剖位置。Functionally stable osteosynthesis using miniplates 使用迷你型接骨板保持接骨术的功能性稳定。CraniomaxillofacialLeFort II Fracture:Placement of Mini PlatesLeFort II 型骨折：迷你型接骨板的放置型骨折：迷你型接骨板的放置One 1.2 or 1.7 mm plate to

36、stabilize the nasofrontal region鼻额区固定一块鼻额区固定一块1.2mm或或1.7mm的接骨的接骨板。板。One 1.2 or 1.7 mm plate on the infraorbital rim 眶下缘放置一块眶下缘放置一块1.2mm或或1.7mm的接骨的接骨板。板。One 1.7/2.0 mm plate on the nasomaxillary buttress在鼻上颌支上放置一块在鼻上颌支上放置一块1.7mm或或2.0mm的接骨板。的接骨板。One 1.7/2.0 mm plate on the zygomaticomaxillary buttress

37、在颧上颌支上放置一块在颧上颌支上放置一块1.7mm或或2.0mm的接骨板。的接骨板。CraniomaxillofacialLeFort III Fracture/Treatment LeFort III 型骨折型骨折/治疗治疗LeFort III Fracture LeFort III 型骨折Le Fort III fractures result in disconnection of the face from the cranium LeFort III 型骨折会导致面部与头盖骨的离断。Goes through nasomaxillary and nasofrontal sutures骨

38、折线贯穿鼻额缝及鼻上颌缝LeFort III Fracture Treatment LeFort III 型骨折的治疗MMF to re-establish the correct occlusion 通过MMF恢复正常的密闭结构。Reduction of the fracture in anatomically correct position恢复断骨的正常解剖位置。Functionally stable osteosynthesis by the means of miniplates使用迷你型接骨板保持接骨术的功能性稳定。CraniomaxillofacialLeFort III App

39、roachesLeFort III 型骨折手术入路型骨折手术入路 Lateral brow,upper lid blepharoplasty,or bicoronal 眉弓外侧：上睑成形术入路或双侧冠状切口 ZF suture颧颌缝 Bicoronal incision双侧冠状切口 Naso-orbital-ethmoidal fracture鼻-眶-筛骨折 Subcilliary,Transconjunctival,Infraorbital Rim睫下、经结膜、眶下缘 Infrorbital rim,orbital floor眶下缘、眶底 Intraoral/Vestibular Incis

40、ion经口内/前庭切口 Maxilla(LeFort I fracture)上颚（LeFort I 型骨折）CraniomaxillofacialLeFort III Fracture:Placement of Mini Plates LeFort III型骨折：迷你型接骨板的放置型骨折：迷你型接骨板的放置One 1.2 mm plate to stabilize the naso-orbital-ethmoidal fracutre用一块1.2mm的接骨板稳定鼻-眶-筛的骨折。One 1.2 or 1.7mm plate to stabilize the zygomaticofrontal

41、suture 用一块1.2或1.7mm的接骨板稳定颧额缝。CraniomaxillofacialLeFort III Fracture StabilizationLeFort III型骨折的稳定型骨折的稳定Stabilization!稳定CraniomaxillofacialLeFort Osteotomies LeFort式截骨术式截骨术LeFort osteotomies follow the fracture lines described by LeFort.LeFort截骨术是按照LeFort提出的骨折线进行截骨的术式。LeFort ILeFort III osteotomy for

42、 midface advancementLeFort III截骨术用于面中部前突的矫形。CraniomaxillofacialFrontal Bone/Sinus Fractures额骨额骨/额窦骨折额窦骨折Includes the following anatomy包括以下解剖结构：Frontal sinus 额窦 Inner(posterior)and outer(anterior)tables 内部的（后）及外部的（前）格 Nasofrontal duct鼻额管CraniomaxillofacialFrontal Sinus Fracture-Anterior and Posterior

43、 Tables额窦骨折及前后格额窦骨折及前后格包括鼻额管包括鼻额管硬脊膜撕裂和CFS漏液CraniomaxillofacialClinical Example:Frontal Sinus Fracture临床病例：额窦骨折临床病例：额窦骨折CraniomaxillofacialTreatment of Frontal Bone Fractures额骨骨折的治疗额骨骨折的治疗Anatomic reduction解剖位置解剖位置修复修复 Supraorbital bar contour眶上眶上缘缘轮廓轮廓 Orbital roof fixation 眶底眶底固定固定 Plates接接骨骨板板 Me

44、sh 网板网板Remove sinus septum去除去除窦隔窦隔Obliteration for fronto-nasal duct injury解除解除鼻额管损伤鼻额管损伤CraniomaxillofacialPan Facial Fractures全面部骨折全面部骨折Complete loss of reference points参照点全部丢失HEIGHT高度PROJECTION投影WIDTH宽度High energy/velocity injury高能/高速损伤Most all major structures/buttresses fractured大部分主要结构/支柱都发生骨折

45、。CraniomaxillofacialPanfacial Fractures全面部骨折全面部骨折Lateral外侧 Zygomatic arch颧弓 Lateral Orbital Rim眶外侧Superior上部 Frontal Bone额骨 Naso-orbital-ethmoidal鼻-眶-筛Medial 中部 Infraorbital rim眶下缘 Maxillary buttresses 上颌支Inferior下部 Mandible下颌骨CraniomaxillofacialPanfacial Treatment Basics全面部骨折的基础治疗全面部骨折的基础治疗Good pre

46、-operative planning良好的术前规划 accurate imaging&fracture classification精确的影像及骨折分类Restore premorbid occlusion 恢复闭合结构 MMF key to establishing bite MMF的关键是锚定Priority of fracture fixation骨折固定的优先顺序 superior,middle,inferior thirds上部、中部、下部Approaches to Repair:Bottom up,top down,inside out,outside in修复顺序：由下到上、由上到下、由内及外、由外到内