上颌面中颌面骨折解剖形态综述

上颌面中颌面骨折解剖形态综述Midface面中部

TheMidfaceisprisedprimarilybyTwoBones:面中部主要包括两块骨骼:TheMaxilla&theZygoma上颌骨和颧骨Maxillaryfracturesaccountforapproximately10%to20%ofallfacialfractures

在所有面部骨折中上颌骨骨折得发生率约为10%-20%。Buttresses支柱效应

Supportpillarsofthefaceandtheytransmitforcestothebaseoftheskull、像柱子一样支撑面部并将压力传导到头盖骨底部。Reconstructionofthesebuttressesisthekeytomaxillary/midfacialrepair(andthegeneralprincipleofplateosteosynthesis)在上颌骨/面中部骨折得修复中重建这些支柱非常关键(这也就是颌面修复接骨板应用得普遍原则)。Buttresses支柱效应

Vertical垂直得Pterygomaxillary(posterior)翼突上颌(后面)Zygomatico-maxillary(lateral)颧骨上颌(侧面)Nasomaxillary(medial)鼻上颌(中间)Horizontal水平得Nasofrontal(supraorbitalrims)鼻骨额骨(眼眶上缘)Nasomaxillary(inferiororbitalrims)鼻上颌(眼眶下壁)Inferiorborderofmandible下颌骨下缘

Horizontal Vertical

水平得垂直得FrontalBone额骨NasalBones鼻骨Ethmoid筛骨LacrimalBone泪骨Zygoma颧骨Maxilla上颌骨AlveolarProcess牙槽突Craniomaxillofacial(CMF)Trauma

颅颌面(CFM)外伤

Directexposureandfixationofthesebuttressesprovidesanatomicalrestoration、

直接暴露并固定这些支柱有助于解剖结构得恢复。Maingoalistorestore:修复得主要目标:Height高度Width宽度Projection投影SurgicalExposureSelection

术野选择Cosmeticappearance,inconspicuousarea对外表影响较小得不明显得区域。Avoidwhenpossiblemusclesandnerves尽量避开肌肉及神经。Sensorynervesandcranialnerves感觉神经及颅神经Alsoconsideruniqueanatomyofpatient还要考虑到患者解剖结构得特殊性。Utilizeopenwoundsforexposuretofracturesite利用开放得伤口暴露出骨折得位置。Exposureofthemaxilla:暴露上颌骨Intraoral:vestibularincision/Sublabial/Gingivobuccalsulcus

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Lateralbrow眉弓外侧Coronal冠状UpperEyelid/Blephoroplasty

上睑/内眼角Zygoma:颧骨:Gillies

Gillies入路Coronal冠状Lateralbrow眉弓外侧Blepharoplasty眼睑成形术Naso-orbital-ethmoidal:鼻-眶-筛bicoronalincision双侧冠状切口Upper/MidFaceSurgicalApproaches

上面部/面中部手术入路

CoronalApproach冠状入路

Toaccess:Zygomaticarch,Superior,medial&lateralorbitalrims,NasoethmoidalRegion,andFrontalSinus可进入:颧弓、眼眶前部、中间及后部、鼻筛区及额陡11大家应该也有点累了，稍作休息大家有疑问的，可以询问和交流CoronalApproach

冠状入路Pericranium颅骨膜CoronalApproach

冠状入路GilliesApproach

Gillies入路

ForClosedReductionofaZygomaFracture

用于颧骨骨折得闭合性复位UpperLidBlepharoplasty

上眼睑成形术入路ZygomaFractures,FrontozygomaticSutureLine,andOrbitalRoofFractures,Lateralbrow颧骨骨折、额颧缝及眶顶骨折、眉弓外侧LateralBrowIncision

眉弓外侧切口ZygomaFractures,FrontozygomaticSutureLine,andOrbitalRoofFractures,Lateralbrow颧骨骨折、额颧缝及眶顶骨折、眉弓外侧LateralBrowIncision

眉弓外侧切口TransconjunctivalApproach

经结膜入路InferiorOrbitalRim,OrbitalFloor,ZMCfractures,LateralRim,andMedialWall前眶部、眶底、颧颌骨折、眶外侧壁及内侧壁SubcilliaryApproach

睫下入路InferiorOrbitalRim,OrbitalFloor,ZMCfracturesandLateralRim眶下缘、眶底、颧颌骨折、眶外侧InfraorbitalIncision

眶下切口InferiorOrbitalRim,OrbitalFloor,ZMCfracturesandLateralRim眶下缘、眶底、颧颌骨折、眶外侧

SubtarsalApproach

跗骨下入路

SubtarsalApproach

跗骨下入路TarsalPlate睑板

PeriorbitalIncisions

眶周切口LateralBrow眉弓外侧UpperEyelid/Blepharplasty上睑/睑成形术Transconjunctival经结膜Subciliary睫下Subtarsal跗骨下Infraorbital眶下Vestibular/Sublabial/GingivobuccalSulcusIncision前庭/唇下/牙龈槽切口Vestibular/Sublabial/GingivobuccalSulcusIncision前庭/唇下/牙槽沟切口Vestibular/Sublabial/

GingivobuccalSulcusIncision

前庭/唇下/牙槽沟切口UniversalUpperface/Midface

通用上面部/面中部ZygomatiaxillaryplexFracture(ZMC)

颧颌复合体骨折(ZMC)Mostmonmidfacefracture!就是最常见得中面骨折ZygomaFracture:SurgicalApproaches

颧骨骨折:外科手术入路Lateralbrowincision(inorbelowtheeyebrow)foraccesstotheZFsuture眉弓外侧切口(在眉毛里或在眉毛下)达到颧骨骨折线。Vestibularincisionforaccesstothezygomatiaxillarybuttress前庭切口可以暴露颧颌支。Subciliary,transconjunctival,subtarsal,orinfraorbitalfortheinferiororbitalrimandorbitalfloor睫下、经结膜、跗骨下或眶下入路用于暴露眶下部及眶底。Gillies:RepositionofthezygomatemporallyGillies入路:可用于颧骨得临时复位。Transbuccal(sharphookorbonerepositioningpin)经颊得(可应用锐钩或骨复位针)ZMCFracture:Treatment

颧颌复合体骨折:治疗Exposureofthefracturesites

暴露骨折位点。Reductionofthefracturedbonewithasharphookorrepositioningpin

用锐钩或复位针将断骨复位。Functionallystableplateosteosynthesis

功能性稳定得接骨术ZMCFracture:RepositioningPin

颧颌复合体骨折:复位针TransbuccalStabIncision经颊针刺切口ClassificationofZMCFractures

颧颌复合体骨折得分类Increasingdisplacement位移增大Occulardystopia异位Flatcheekbonecosmeticdeformity颧弓变平Increasedminuting加重粉碎损伤Floor&lateralwalldisruption底部及外侧壁断裂ZMCFractureTypes

颧颌复合体骨折类型第1类第2类第3类第4类Type1&2ZMCTreatment

第1类及第2类颧颌复合体骨折得治疗Reduction修复Twopointfixationwithrigidminiplates(1、2/1、7mm):用微型硬接骨板(1、2/1、7mm)进行两点固定 ZFsuture& Inferiororbitalrim

颧颌缝及眶下缘Type3ZMCTreatment

第3类颧颌复合体骨折Reduction修复Wireinterfragmentaryalignment线性骨折Threepointfixation:三点固定 ZFsuture颧颌缝 InferiorOrbitalRim眶下缘 Zygomatiaxillarybuttress

颧颌支Type4ZMCTreatment

第4类颧颌复合体骨折Reduction修复Fragmentstabilization稳定断骨片+/-Bonegrafting

±骨移植4pointfixation:四点固定:

ZFsuture颧颌缝 InferiorOrbitalRim眶下缘

Zygomatiaxillarybuttress颧颌支 Zygomaticarch颧弓OrbitalInvolvementwithZMCFracture

合并有眼眶损伤得颧颌复合体骨折Fracturesofthezygomaarealwaysconnectedwithfracturesoftheorbitalfloor颧骨得骨折总就是伴随着与之相连得眶底骨折Fracturesite骨折点OpticalCanal视神经管ZygomaticSuture颧颌缝InfraorbitalRim眶下缘InfraorbitalForamen眶下孔BonesoftheOrbit

眶骨得组成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(Gold)筛骨(金色)Sphenoid(Green)蝶骨(绿色)

LateralOrbitalrim外侧壁MedialorbitalRim内侧壁Medialwall内壁Inferiororbitalrim下侧壁SuperiorOrbitalRim上壁Behindtheeye后眼窝Behindtheeye后眼窝Patient’slefteye患者得左眼SuperiorViewofInferiorOrbitalRim眶下壁俯视图OrbitalFloorwithZMCFracture

颧颌复合体复合眶下壁骨折Fracturesarereducedpriortoorbitalfloorreconstruction将断骨复位后再重建眶底。BasicOrbitalFloorPlate

基本眶底修复板Connectionbarsareanchoredtoinfraorbitalrim

将连杆锚定在眶下缘。Floorplatesextendoverrimplate

底板要长于边缘板。SuperiorViewofAnteriorOrbit

前眶俯视图Connectionbarstrimmedoffandfixatedtoinnersurfaceoforbitalrim

将连杆平行固定在眶缘表面。Platecovers75%oftheorbitalfloor

修复板要覆盖眶底得75%。“BlowOut”Fracture

“眼眶爆裂性”骨折眶底骨折脱垂到骨折部位得脂肪和肌肉包埋组织Enopthalmos-眼球内陷recessionoftheeyeballwithintheorbit眼球随着眼眶一起下陷associatedwithZMC/Orbitalfloorfractures伴随有颧颌复合体或眶底得骨折正常眼球内陷IsolatedOrbitalFloorFracture

眶底离断性骨折Orbitalfloorshownwithfracture眶底骨折示意图NoZMCfractureponent:Orbitalrimandthezygomaticplexstayintact未合并颧颌复合体骨折因素:眶缘及颧骨保持完整IsolatedOrbitalFloorFracture

眶底离断性骨折IsolatedOrbitalFloorPlate

眶底离断性骨折接骨板Smallplateisfixatedwith1、2mmscrews小接骨板用1、2mm螺钉固定。Connectionbarsarebentupandovertheinfraorbitalrim连杆弯曲向外越过眶下缘。Naso-Orbital-Ethmoidal(NOE)FractureTypes

鼻-眶-筛(NOE)骨折得类型Type1第1类singlesegment(lateralorcentralfragment)单纯性断裂(侧面或中间部断裂)Type2第2类minutedcentralfragment(fracturesexternaltomedialcanthaltendoninsertion)中部粉碎性断裂(骨折延伸到内眦附着端)Type3第3类minutedcentralfragment(fracturesincludingboneofcanthaltendoninsertion)中部复合性断裂(骨骼包括内眦附着端得骨折)TypesofMidfaceFractures

面中部骨折得类型Dr、ReneLeFortstudiedfacialfracturepatternsReneLeFort医生对面骨得骨折类型进行了研究。Identified3linesofweaknessinthefacialskeleton定义了3条面部骨骼最脆弱得线。Theselinesofweaknesscorrespondtothesitesofmostfrequentmidfacialfractures、这些线得分布与面部骨折频发得位置相符合。LeFortI,LeFortII,LeFortIII/LeFortI、LeFortII、LeFortIIILeFortFracturePatterns

LeFort骨折类型1:LeFortI2:LeFortII3:LeFortIII上颌骨–从下向上骨折LeFortIFracture/Treatment

LeFortI骨折/治疗LeFortIFractureLeFortI骨折Resultsina“floatingpalate”导致“上颚游离”。Fracturegoesthroughpiriformaperatureandisconsideredbilateral骨折线穿过前鼻孔向两侧延伸。LeFortIFractureTreatmentLeFortI骨折得治疗Approaches入路Intraoral(Vestibularincision)1、口内入路(前庭切口)MMFtoreestablishthecorrectocclusion利用MMF重建正常得闭合结构。Reductionofthefracturetotheanatomicallycorrectposition修复断骨重建正常解剖结构。Functionallystableosteosynthesisbymeansofminiplatesonthebuttresses在支柱上使用迷您型接骨板保持接骨术得功能性稳定。Exposureofthefracturesiteintraorally经口内暴露骨折位点LeFortIFracture:PlacementofMiniPlates

LeFortI型骨折:迷您型接骨板得放置Twoplatesoneachside每侧放置两块接骨板OnestraightorL-shapeplate(1、7or2、0mm)onthenasomaxillarybuttressorpiriformaperture在鼻上颌支或前鼻孔处放置一块直型或L型接骨板(1、7mm或2、0mm)。OnestraightorL-shapeplate(1、7or2、0mm)onzygomatiaxillarybuttress另一块直型或L型接骨板(1、7mm或2、0mm)放在颧颌支上。LeFortIIFracture/Treatment

LeFortII型骨折/治疗LeFortIIFractureLeFortII型骨折LeFortIIfracturesresultinmobilityofthemaxillaryandnasalplexLeFortII型骨折会导致上颌及鼻骨得游离。Goesthroughzygomatiaxillarysuture(lateralorbitalrim)骨折线穿过颧颌缝(眶侧面)LeFortIIFractureTreatmentLeFortII型骨折得治疗Approaches入路Infraorbital:subciliaryortransconjunctival眶下入路:睫下或经结膜得Intraoral(vestibular):maxilla口内入路(前庭)上颚Coronal:nasoethmoidal冠状入路:经鼻筛得MMFtoreestablishthecorrectocclusion利用MMF来恢复正常得密闭结构。Reductionofthefractureinanatomicallycorrectposition恢复断骨得正常解剖位置。Functionallystableosteosynthesisusingminiplates使用迷您型接骨板保持接骨术得功能性稳定。LeFortIIFracture:PlacementofMiniPlates

LeFortII型骨折:迷您型接骨板得放置One1、2or1、7mmplatetostabilizethenasofrontalregion鼻额区固定一块1、2mm或1、7mm得接骨板。One1、2or1、7mmplateontheinfraorbitalrim眶下缘放置一块1、2mm或1、7mm得接骨板。One1、7/2、0mmplateonthenasomaxillarybuttress在鼻上颌支上放置一块1、7mm或2、0mm得接骨板。One1、7/2、0mmplateonthezygomatiaxillarybuttress在颧上颌支上放置一块1、7mm或2、0mm得接骨板。LeFortIIIFracture/Treatment

LeFortIII型骨折/治疗LeFortIIIFractureLeFortIII型骨折LeFortIIIfracturesresultindisconnectionofthefacefromthecranium

LeFortIII型骨折会导致面部与头盖骨得离断。Goesthroughnasomaxillaryandnasofrontalsutures骨折线贯穿鼻额缝及鼻上颌缝LeFortIIIFractureTreatmentLeFortIII型骨折得治疗MMFtore-establishthecorrectocclusion通过MMF恢复正常得密闭结构。Reductionofthefractureinanatomicallycorrectposition恢复断骨得正常解剖位置。Functionallystableosteosynthesisbythemeansofminiplates使用迷您型接骨板保持接骨术得功能性稳定。LeFortIIIApproaches

LeFortIII型骨折手术入路

Lateralbrow,upperlidblepharoplasty,orbicoronal眉弓外侧:上睑成形术入路或双侧冠状切口ZFsuture颧颌缝Bicoronalincision双侧冠状切口Naso-orbital-ethmoidalfracture鼻-眶-筛骨折Subcilliary,Transconjunctival,InfraorbitalRim睫下、经结膜、眶下缘Infrorbitalrim,orbitalfloor眶下缘、眶底Intraoral/VestibularIncision经口内/前庭切口Maxilla(LeFortIfracture)上颚(LeFortI型骨折)LeFortIIIFracture:PlacementofMiniPlates

LeFortIII型骨折:迷您型接骨板得放置One1、2mmplatetostabilizethenas