上颌面中颌面骨折解剖形态综述uppermidface课件

1、Universal Neuro 21.2mm Upper-Face Module1.2mm上面部模块1.7mm Mid-Face Module1.7mm面中部模块Universal Mandible下颌通用套件Mini-Plating System迷你接骨板系列Universal Neuro2系列Mini-Plating System迷你接骨板系列Universal Neuro 21.2mm Upper-FUpper Face/ Mid Face上面部/面中部Upper Face/ Mid Face上面部/面中部Midface面中部The Midface is comprised primar

2、ily by Two Bones:面中部主要包括两块骨骼：The Maxilla & the Zygoma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%。Midface面中部The Midface is compButtresses支柱效应Support pillars of the face and they transmit forces to the base of the skull.像柱子一样支撑面部并将压力

3、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）。Buttresses支柱效应Support pillarsButtresses支柱效应Vertical垂直的Pterygomaxillary (posterior)翼突上颌（后面）Zygomatico-maxillary (lateral)

4、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Buttresses支柱效应Vertical垂直的 Horizontal Vertical 水平的 垂直的 Horizontal VertFrontal Bone额骨Nasal Bones鼻骨Ethmoid筛骨Lacrimal Bone泪骨Zygoma颧骨M

5、axilla上颌骨Alveolar Process牙槽突Frontal Bone额骨Craniomaxillofacial (CMF) Trauma颅颌面（CFM）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Craniomaxillofacial (CMF) TrauSurgical Exposure Selec

6、tion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骨折的位置。Surgical Exposure Selection术野

7、Exposure 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入路Coronal冠状Lateral brow眉弓外侧Blepha

8、roplasty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/面中部手术入路Exposure of the maxilla:ZygomaCoronal Approach冠状入路To access: Zygomatic arch, Superior, medial & lateral orbital rims, Naso ethmoidal Region, and Frontal Sinus可进入：颧弓、眼眶前部、中间及后部、鼻筛区及额陡Coronal

9、Approach冠状入路To accessCoronal Approach冠状入路Pericranium颅骨膜Coronal Approach冠状入路PericraniCoronal Approach冠状入路Coronal Approach冠状入路Gillies Approach Gillies 入路For Closed Reduction of a Zygoma Fracture用于颧骨骨折的闭合性复位Gillies Approach Gillies 入路FUpper Lid Blepharoplasty上眼睑成形术入路Zygoma Fractures, Frontozygomatic Su

10、ture Line, and Orbital Roof Fractures, Lateral brow颧骨骨折、额颧缝及眶顶骨折、眉弓外侧Upper Lid Blepharoplasty上眼睑成形Lateral Brow Incision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Lateral Brow Incision眉弓外侧切口ZyLateral Brow Incision眉弓外侧切口Lateral Brow I

11、ncision眉弓外侧切口Transconjunctival Approach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Transconjunctival Approach经结膜Subcilliary Approach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Subcilliary Approach睫下

12、入路InferInfraorbital Incision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Infraorbital Incision眶下切口Infe Subtarsal Approach跗骨下入路 Subtarsal Approach跗骨下入路 Subtarsal Approach跗骨下入路Tarsal Plate睑板 Subtarsal Approach跗骨下入路Tarsa Periorbital Incisions眶周切口Lateral Brow眉弓外侧U

13、pper Eyelid/Blepharplasty上睑/睑成形术Transconjunctival经结膜Subciliary睫下Subtarsal跗骨下Infraorbital眶下 Periorbital Incisions眶周切口LatVestibular/Sublabial/Gingivobuccal Sulcus Incision前庭/唇下/牙龈槽切口Vestibular/Sublabial/Vestibular/Sublabial/Gingivobuccal Sulcus Incision前庭/唇下/牙槽沟切口Vestibular/Sublabial/Vestibular/Sublab

14、ial/ Gingivobuccal Sulcus Incision前庭/唇下/牙槽沟切口Vestibular/Sublabial/ GingivoUniversal Upperface/Midface通用上面部/面中部Universal Upperface/Midface通用Zygomaticomaxillary Complex Fracture (ZMC)颧颌复合体骨折（ZMC）Most common midface fracture!是最常见的中面骨折Zygomaticomaxillary Complex FrZygoma Fracture: Surgical Approaches颧骨骨

15、折：外科手术入路Lateral 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

16、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）Zygoma Fracture: Surgical ApprZMC Fracture: Treatment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

17、 repositioning pin用锐钩或复位针将断骨复位。Functionally stable plate osteosynthesis功能性稳定的接骨术ZMC Fracture: Treatment颧颌复合体骨ZMC Fracture: Repositioning Pin颧颌复合体骨折：复位针Transbuccal Stab Incision经颊针刺切口ZMC Fracture: Repositioning PiClassification of ZMC Fractures颧颌复合体骨折的分类Increasing displacement位移增大Occular dystopia异位Fl

18、at cheekbone cosmetic deformity颧弓变平Increased comminuting加重粉碎损伤Floor & lateral wall disruption 底部及外侧壁断裂Classification of ZMC FractureZMC Fracture Types颧颌复合体骨折类型第1类第2类第3类第4类ZMC Fracture Types颧颌复合体骨折类型第1Type 1 & 2 ZMC Treatment第1类及第2类颧颌复合体骨折的治疗Reduction修复Two point fixation with rigid miniplates (1.2/1.

19、7mm):用微型硬接骨板（1.2/1.7mm）进行两点固定ZF suture &Inferior orbital rim颧颌缝及眶下缘Type 1 & 2 ZMC Treatment第1类及第Type 3 ZMC Treatment第3类颧颌复合体骨折Reduction 修复Wire interfragmentary alignment线性骨折Three point fixation:三点固定ZF suture颧颌缝Inferior Orbital Rim眶下缘Zygomaticomaxillary buttress 颧颌支Type 3 ZMC Treatment第3类颧颌复合体骨Type 4

20、 ZMC Treatment第4类颧颌复合体骨折Reduction修复Fragment stabilization稳定断骨片+/- Bone grafting 骨移植4 point fixation:四点固定：ZF suture颧颌缝Inferior Orbital Rim眶下缘Zygomaticomaxillary buttress颧颌支Zygomatic arch颧弓Type 4 ZMC Treatment第4类颧颌复合体骨Orbital Involvement with ZMC Fracture合并有眼眶损伤的颧颌复合体骨折Fractures of the zygoma are alwa

21、ys 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Fracture site骨折点Optical Canal视神经管Zygomatic Suture颧颌缝Infraorbital Rim眶下缘Infraorbital Foramen眶下孔Orbital Involvement with ZMC FBones of the Orbit眶骨的组成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(

22、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Bones of the Orbit眶骨的组成LateraSuperior View of Inferior Orbital Rim眶下壁俯视图Superior View of Inferior OrbiOrbital Fl

23、oor with ZMC Fracture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。Orbital Floor with ZMC FracturBasic Orbital Floor Plate基本眶底修复板Connection bars are anchored to infraorbital rim将连杆锚定在眶下缘。Floor plates extend over rim plate底板要长于边缘板。Basic Orbital Floor Plate基本眶底Supe

24、rior View of Anterior Orbit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%。Superior View of Anterior Orbi“Blow Out” Fracture“眼眶爆裂性”骨折眶底骨折脱垂到骨折部位的脂肪和肌肉包埋组织“Blow Out” Fracture“眼眶爆裂性”骨折Enopthalmos- 眼球内陷recession

25、 of the eyeball within the orbit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眶底的骨折正常眼球内陷Enopthalmos- 眼球内陷正常眼球内陷Isolated Orbital Floor Fracture眶底离断性骨折Orbital floor shown with fracture眶底骨折示意图No ZMC 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

26、持完整Isolated Orbital Floor FracturIsolated Orbital Floor Fracture眶底离断性骨折Isolated Orbital Floor FracturIsolated Orbital Floor Plate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 bent up and over the infraorbital rim连杆弯曲向外越过眶下缘。Isolated Orbital Floor Plate眶Naso-Orb

27、ital-Ethmoidal (NOE) Fracture Types鼻-眶-筛（NOE）骨折的类型Type 1第1类single segment (lateral or central fragment)单纯性断裂（侧面或中间部断裂）Type 2第2类comminuted central fragment (fractures external to medial canthal tendon insertion)中部粉碎性断裂（骨折延伸到内眦附着端）Type 3第3类comminuted central fragment (fractures including bone of canth

28、al tendon insertion)中部复合性断裂（骨骼包括内眦附着端的骨折）Naso-Orbital-Ethmoidal (NOE) FTypes of Midface Fractures面中部骨折的类型Dr. Rene Le Fort studied facial fracture patternsRene Le Fort 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 o

29、f 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 IIITypes of Midface Fractures面中部LeFort Fracture Patterns LeFort骨折类型1: LeFort I2: LeFort II3: LeFort III上颌骨 从下向上骨折LeFort Fracture Patterns LeFoLeFort I Fracture/Treatment LeFort

30、I骨折/治疗LeFort I FractureLeFort I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Approaches入路Intraoral(Vestibular incision )1.口内入路（前庭切口）MMF to reestablish the correct occlusion 利用MMF重建正

31、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 the fracture site intraorally经口内暴露骨折位点LeFort I Fracture/Treatment LLeFort I Fracture: Placement of Mini Pl

32、ates LeFort I 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 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)

33、 放在颧颌支上。LeFort I Fracture: Placement oLeFort II Fracture/Treatment LeFort II 型骨折/治疗LeFort II Fracture LeFort II 型骨折LeFort II fractures result in mobility of the maxillary and nasal complexLeFort II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 Frac

34、ture Treatment LeFort II 型骨折的治疗Approaches入路Infraorbital: subciliary or transconjunctival眶下入路：睫下或经结膜的Intraoral (vestibular): maxilla口内入路（前庭）上颚Coronal: nasoe thmoidal冠状入路：经鼻筛的MMF to reestablish the 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。

35、Functionally stable osteosynthesis using miniplates 使用迷你型接骨板保持接骨术的功能性稳定。LeFort II Fracture/Treatment 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 plate to stabilize the nasofrontal region鼻额区固定一块1.2mm或1.7mm的接骨板。One 1.2 or 1.7 mm plate on the infraorbital rim 眶下

36、缘放置一块1.2mm或1.7mm的接骨板。One 1.7/2.0 mm plate on the nasomaxillary buttress在鼻上颌支上放置一块1.7mm或2.0mm的接骨板。One 1.7/2.0 mm plate on the zygomaticomaxillary buttress在颧上颌支上放置一块1.7mm或2.0mm的接骨板。LeFort II Fracture: Placement LeFort III Fracture/Treatment LeFort III 型骨折/治疗LeFort III Fracture LeFort III 型骨折Le Fort II

37、I 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

38、 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。LeFort III Fracture/TreatmentLeFort III ApproachesLeFort III 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-et

39、hmoidal 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 Incision经口内/前庭切口Maxilla (LeFort I fracture)上颚（LeFort I 型骨折）LeFort III ApproachesLeFort ILeFort III Fracture: Placement of Mini Plates LeFort III型骨折：迷你型接骨板的放置One 1

40、.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 suture 用一块1.2或1.7mm的接骨板稳定颧额缝。LeFort III Fracture: PlacementLeFort III Fracture StabilizationLeFort III型骨折的稳定Stabilization!稳定LeFort III Fracture StabilizatLeFor

41、t Osteotomies LeFort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 midface advancementLeFort III截骨术用于面中部前突的矫形。LeFort Osteotomies LeFort式截骨术Frontal Bone/Sinus Fractures额骨/额窦骨折Includes the following anatomy包括以下解剖结构：Frontal sinus 额窦