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TRAUMA MAXILLO-FACIALDr. Jan Tumatar Ngantung, SpB, SpBP.DIVISI BEDAH PLASTIK, BAGIAN BEDAHFAKULTAS KEDOKTERAN UNSRAT MANADO
MAXILLO FACIAL INJURIESFACIAL BONESUPPER THIRDMID THIRD LOWER THIRDFRONTALFACIAL SOFT TISSUE
EVALUATING OF MAXILLO FACIAL INJURIES HISTORY TAKING : Injury Mechanism. Associated Injuries.
PHYSICAL EXAMINATION : Most Facial Fractures can be Identified by Clinical examination.
RADIOLOGICAL EXAMINATION : Plain X-Ray, CT Scan.
INJURY MECHANISM
INJURY MECHANISM
INJURY MECHANISM
ASSOCIATED INJURIES TRAUMA CAPITIS 58,3 % TRAUMA CERVICALIS 5,3 % TRAUMA THORAX.. 19 % TRAUMA ABDOMEN.. 10 % TRAUMA TULANG (EXTREMITY) 6 % TRAUMA SPINALIS 1,4 %
BONE FRACTURED NASAL BONES/ FRONTAL 29 %. MANDIBLE/ ALVEOLAR 44 %. MAXILLA / ZYGOMA 24 %. OTHERS 3 %.JEFTA (RSCM, 2002.)
TITIK LEMAH MAXILLO-FACIAL
DIAGNOSA FRAKTUR Anamnese adanya Trauma. Perdarahan. Malocclusio Dentis. Asimetris muka. Dapat diraba (palpasi)
PHYSICAL EXAMINATIONMALAR EMINENCE ZYGOMATIC ARCH
PHYSICAL EXAMINATIONSUPERIOR ORBITAL RIMINFERIOR ORBITAL RIM
PHYSICAL EXAMINATION
MANDIBULA
MAXILLAMAXILLA
RADIOLOGIC EVALUATION PLAIN FOTO :AP / LAT POSITION.WATERS POSITION.CALDWELL VIEW.PANORAMIC VIEW.SUBMENTO VERTICAL VIEW.OBLIQUE VIEW.
CT SCANING.AXIAL TOMOGRAPHY.THREE DIMENTIONAL (3 D) IMAGING.
MRI.
RONTGENOGRAPHIC EVALUATION PRIMARY FRACTURE LINED. ANALYSIS OF SECONDARY SIGN OF FRACTURES.OPACITY OF THE NORMAL AIR FILLED SPACES. PARANASAL SINUS.NASAL CAVITY.NASOPHARYNGEAL AIRWAY.OROPHARYNGEAL AIRWAY.THE SYMMETRICITY.ABNORMAL SOFT TISSUE EMPHYSWEMA.
THE POSITIONPOSTERO ANTERIOR CALDWELL
THE POSITIONPANORAMIC VIEWWATERS POSITION
CT SCAN3-D IMAGINGAXIAL TOMOGRAPHIC
CONSEP OF MANAGEMENT CONSERVATIVE DELAYED OPERATIVE REPAIR.
EARLY AGGRESSIVE ONE STAGE OPERATIVE REPAIR.
PROTOCOL Soft Tissue Management : Should be perform immediately. Maybe delayed until 12 - 24 hours (Owing to the vascularity of the Head and Neck).
Bony Injury Management : Immediately (open fractures). Maybe delayed for 2 weeks (close fractures of small / thin bones )
PRINSIP PENANGANAN AIRWAY MANAGEMENT ANATOMIC STRUCTURES WOUND MANAGEMENT
ACUTE MANAGEMENT OF FACIAL INJURY PRIORITY : A : Airway, B : Breathing, C : Circulation..
PARTICULAR ATTENTION. Obstruction due to : - Midfacial collaps, - Tongue retention Maxillofacial or Oronasal bleeding Associated Head Injuries. C-Spine Injury.
TEMPORARY IMMOBILISATION.
AIRWAYS MANAGEMENT Bersihkan Jalan Nafas : Singkirkan bekuan darah dan Corpus alienum. Kontrol kedudukan Lidah. Perhatikan Posisi Kepala.
Tracheostomy / Intubasi Endotracheal Pd keadaan darurat : Endotracheal Intubation akan > siap dp tracheostomy (krn procedur tracheostomi akan > bersifat elective operasi dgn tahapan2 prosedurnya). Kecuali bila ada fracture / masa yg mengganggu jalan nafas maka sebaiknya dgn tracheostomi.
BLEEDING PRESSURE. TAMPOON. LIGATION (to the bleeding point)TAMPOON HIDUNG
TEMPORER IMMOBILISATION
TRAUMA JARINGAN LUNAK Faktor Estetik, sangat menentukan keberhasilan penanganan. Jaringan muka sangat kaya akan pembuluh darah TEHNIKNYA :Cuci dengan cairan fisiologis yg mengalir.Debridement Luka, membuang jaringan sesedikit mungkin.Gunakan benang halus, jarum atraumatis, kurang reaktif.Aproximasi tepian luka yg tepat, dgn jarak yg tepat, tanpa me-ninggalkan dead space / tumpukan drh /jaringan dibawahnya.Perhatikan struktur anatominya.Cabut benang 4-5 hari.
LANGERS LINE
SOFT TISSUE INJURIES
Glandula Parotis. Ductus Stensen (Parotid Duct). Nervus Facialis. Ligamentum Canthus Med / Lat. Palpebrae & Tarsalia Sup / Inf. System Naso-Lacrimalis. Nasal & Cartilago Alaris. Nervus Supra / Infra Orbitalis. Nervus Supra Trochlearis. Nervus Alveolaris Inferior. Nervus Mentalis.
DUCTUS PAROTIDEUS STENSEN
LIG. CANTHUS MEDIALEXAMINATIONANATOMI
SISTEM NASOLACRIMALISPUNCTA CANALICULUSAMPULA CANALICULUSDUCTULI
PRINCIPLES OF FRACTURE MANAGEMENT Precise Anatomic Diagnosis Direct / Wide Exposure of Fracture sides. Rigid Internal Fixation. Primary Bone Grafting. Periosteal and Soft Tissue Suspension.
THE GOAL OF FRACTURE MANAGEMENTS Anatomical Reduction and Stabilization. Re-estabilishment of pretraumatic fungtional occlusion. Restoration of Facial Contour/Symmetry. Balance of Facial Height and Projection.
FACIAL SKELETAL STRUCTURE VERTICAL BUTRESS Naso-Maxillary Buttres anterior. Zygomatico-Maxillary Buttres anterior. Pterigo-Maxillary Buttres posterior.
HORIZONTAL BUTTRES Frontal Bar (supraorbital bar) Infra Orbital Rim + Zygomatic Arch. Maxillary Alveolar ridge. Basal segment of the Mandible.
FACIAL WIDTH; HEIGHT; PROJECTION
BUTTRESS / PENYANGGAH- HORIZONTAL BUTTRES : - Frontal Bar (supraorbital bar). - Infra Orbital Rim + Zygomatic Arch. - Maxillary Alveolar ridge. - Basal segment of the Mandible.
- VERTICAL BUTRESS : - Naso-Maxillary Buttres. - Zygomatico-Maxillary Buttres. - Pterigo-Maxillary Buttres.
- FACIAL WIDTH; HEIGHT;PROJECTION
APPROACH & REDUCTION MULTIPLE INCISION : Bicoronary, Low Lateral, Eye Brow, Subciliary, Trans- conjuntival, Ginggivo-buccal, Submental, Preauriculair.
SUBPERIOSTEAL DISSECTION : Wide and Direct Exposure. Complete Disimpaction and mobilization of fragments.
SEQUENTIAL REDUCTION AND FIXATION Anatomical reduction according to reference points. Obtaining functional occlusion. Determining Facial Width, Height, and Projection.
APPROACHSURGICAL
APPROACHSURGICAL
FIXATION FIXATOR : Steel wire (interdental, intermaxillary, interfragmental, suspension wiring). Bone plate and Screws (miniplate, microplate). Reconstruction plate, Dynamic Compression plate. Biodegradable plate. External Fixator.
PRINCIPLE OF RIGID FIXATION : 3-Dimensional Stabilization. Secure over the horizontal and vertical buttresses.
FIXATIONINTERDENTAL WIRINGINTEROSSEOUS WIRINGBONE PLATEDYNAMIC COMPRESSION PLATE
MANDIBULAANATOMI MANDIBULAMACAM2 FR. MANDIBULA- SIMPLE FRACTURE.- GREENSTICK FRACTURE - FRAGMENTED FRACTURE- COMMUNITED FRACTURE CONDYLUS (36%) - ANGULUS (20%) CORONOID (2%) - CORPUS (21%) RAMUS (3%) - ALVEOLUS (3%) SYMPHYSIS (15%)
ORTHOGNATIC CLASSIFICATIONNORMAL RETROGNATHIC PROGNATHIC
CLASS IICLASS ICLASS III
GAYA2 yg BERPENGARUH pd MANDIBULA PROTRUSIONMm. Pterygoideus lat.
RETRACTION M. Genioglossus. M. Geniohyoideus. M. Mylohyodeus.
ELEVATION M. Temporalis. M. Masseter. M. Pterygoideus Med.
DEPRESSION M. Digastricus.
INWARD DISPLACEMENT M. Pterygoideus Med. M. Pterygoideus Lat.
STABLE FR. UNSTABLE FR.
INTERDENTAL WIRING
INTERMAXILARY WIRING
INTER0SSEOUS WIRING
MAXILLARY BONESFRACTURESA. : L.F. I.: L.F. II.: SEGMENTAL FR.: L.F. III.MAXILLA
TYPE OF MAXILLARY BONE FRACTURESLEE FORTS FRACTURES1. : L.F. I.2. : L.F. II.3. : L.F. III.
REPOSITION OF THE MAXILLARY BONES
SUSPENSION WIRING
FIXATION WITH SUSPENSION WIRINGFOR LEE FORT III FR.
FRACTURES
OF
ZYGOMA1. NO DISPLACEMENT FR.2. ZYGOMATIC ARCH FR.3. UNROTATED ZYGOMA FR.4. & 5. ROTATED ZYGOMA FR.6. COMMINUTED FR. OF ZYGOMA
FRACTURE ZYGOMA
ZYGOMATIC ARCH FR. ROTATED FRACTURE OF ZYGOMA COMMINUTED FRACTURE OF ZYGOMA COMPLEX FRACTURE ZYGOMA BLOWOUT FRACTURE
BLOWOUT FRACTURE DEPRESSED FRACTURE OF THE FLOOR OF THE ORBITAL, WITH PROTRUDING THE CONTENTS OF ORBITAL INTO THE MAXI- LLARY SINUS. SIGN : DIPLOPIA AND ENOPHTHALMOS
SIGN AND SYMPTOMS OF ZYGOMATIC FRACTURE CHEEK AND EYELID EDEMA FLATTENING OF THE CHEEK CIRCUMORBITAL & SUB CONJUNCTIVAL ECCHYMOSIS UNILATERAL EPISTAXIS ANESTHESIA / HYPERESTHESIA OF THE CHEEK PALPABLE DIFORMITY OF THE INFERIOR ORBITAL RIM. LIMITATION OF THE MANDIBULAR MOVEMENT
GILLIES METHODECALDWELL-LUC METHODE
ETIOLOGY FRACTURES NASAL- A. LAT. VIOLENCE.- B. HEAD ON VIOLENCE
MANUAL REPOSITION FOR SIMPLE FRACTURES
CLOSE REPOSITION WITHWALSHAME FORCEP
CLOSE REPOSITION WITHASH FORCEP
PASCA BEDAH Jahitan kulit dicabut hari ke 5. Nasal Pack dicabut hari ke 5. Bone fixation 6 mgg. Salep moisturizer + Sun protector (3 bln).
TERIMA KASIH
PHISICAL EXAMINATION, X RAYCraniofacial fixationMultiple incisionSteel wire,plating