TRAUMA MAXILLOFACIAL

Dr. Jan Tumatar Ngantung, SpB, SpBP.

DIVISI BEDAH PLASTIK, BAGIAN BEDAH

FAKULTAS KEDOKTERAN UNSRAT MANADO

MAXILLO FACIAL INJURIES

FACIAL BONES

FACIAL SOFT TISSUE

FRONTAL
UPPER THIRD

MID THIRD

LOWER THIRD

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 MAXILLOFACIAL

DIAGNOSA FRAKTUR

Anamnese adanya Trauma.

Perdarahan.
Malocclusio Dentis.
Asimetris muka.
Dapat diraba (palpasi)

PHYSICAL EXAMINATION
MALAR EMINENCE

ZYGOMATIC ARCH

PHYSICAL EXAMINATION
SUPERIOR ORBITAL RIM

INFERIOR ORBITAL RIM

PHYSICAL
EXAMINATION

MAXILLA

MAXILLA
MANDIBULA

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 POSITION
POSTERO ANTERIOR

CALDWELL

THE POSITION
WATERS POSITION
PANORAMIC VIEW

CT SCAN
3-D
IMAGING

AXIAL 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 meninggalkan 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 MEDIAL

ANATOMI

EXAMINATION

SISTEM NASOLACRIMALIS
DUCTULI

PUNCTA CANALICULUS
AMPULA CANALICULUS

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, Transconjuntival, 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.

SURGICAL
A
P
P
R
O
A
C
H

SURGICAL
A
P
P
R
O
A
C
H

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.

FIXATION
BONE PLATE

INTERDENTAL WIRING

DYNAMIC COMPRESSION PLATE

INTEROSSEOUS WIRING

ANATOMI MANDIBULA

M
A
N
D
I
B
U
L

- CONDYLUS (36%)

- CORONOID (2%)
- RAMUS (3%)
- SYMPHYSIS (15%)

- ANGULUS (20%)
- CORPUS (21%)
- ALVEOLUS (3%)

MACAM2 FR. MANDIBULA

- SIMPLE FRACTURE.
- GREENSTICK FRACTURE
- FRAGMENTED FRACTURE
- COMMUNITED FRACTURE

CLASS I

ORTHOGNATIC
CLASSIFICATION

CLASS II

CLASS III

NORMAL RETROGNATHIC PROGNATHIC

GAYA2 yg BERPENGARUH pd
MANDIBULA
- PROTRUSION
-Mm. 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

M
A
X
I
L
L
A

MAXILLARY BONES
FRACTURES
A.
B.
C.
D.

:
:
:
:

L.F. I.
L.F. II.
SEGMENTAL FR.
L.F. III.

TYPE OF MAXILLARY BONE FRACTURES

1. : L.F. I.
2. : L.F. II.
3. : L.F. III.

LEE FORTS FRACTURES

REPOSITION OF THE MAXILLARY

BONES

SUSPENSION WIRING

FIXATION WITH
SUSPENSION WIRING
FOR LEE FORT III FR.

F
R
A
C
T
U
R
E
S
O
F

1. NO DISPLACEMENT FR.
2. ZYGOMATIC ARCH FR.
3. UNROTATED ZYGOMA FR.
4. & 5. ROTATED ZYGOMA FR.
6. COMMINUTED FR. OF ZYGOMA

Z
Y
G
O
M
A

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 MAXILLARY 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

CALDWELL-LUC METHODE

GILLIES METHODE

ETIOLOGY FRACTURES NASAL

- A. LAT. VIOLENCE.
- B. HEAD ON VIOLENCE

MANUAL REPOSITION
FOR SIMPLE FRACTURES

CLOSE REPOSITION WITH

WALSHAME FORCEP

CLOSE REPOSITION WITH

ASH 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