Trauma Facialis

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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