Department of operative surgery and topographic anatomy TOPOGRAPHIC ANATOMY OF THE FACIAL PART OF THE HEAD. OPERATIVE TECHNIQUE ON THE HEAD Lecture #2 Lecturer: Associate Professor, Ph.D., Vdovichenko Viacheslav Yurievich Kharkiv, 2015 KHARKIV NATIONAL MEDICAL UNIVERSITY Plan of lecture Topographic anatomy of the facial part of the head. Innervation (n.trigeminus & n.facialis) of the face Operative technique on the Head Traumas of the Head: Specific Specific of wound treatment on the Head Craniotomy: decompresive and osteoplastic Specific of wounds of the Face Fractures of the Upper and Lower Jaw Anesthesia technique of trigeminal nerve a - r.temporalis, b - r.zygomaticus, c - r.buccalis, d - r.marginalis mandibulae, e - r.colli. e Motor Branches of the Facial Nerve The cutaneous nerve supply of the face, scalp and neck. Trigeminal nerve (Cn V) Maxillar nerve (Cn V2) - The intermediate division of the trigeminal nerve is wholly sensory. - It leaves the trigeminal ganglion between the ophthalmic and mandibular divisions to pass through the foramen rotundum. Maxillar nerve (Cn V2) Branches: Meningeal Nerve Branches to the Sphenopalatine Ganglion Zygomatic Nerve Posterior Superior Alveolar Nerve Infraorbital Nerve Location of the Branches of the Maxillary Nerve: In the cranial cavity Meningeal In the pterygopalatine fossa Ganglionic, Zygomatic, Posterior Superior Alveolar In the infraorbital canal Middle superior alveolar, Anterior superior alveolar On the face Palpebral, Nasal, Superior labial The superior dental plexus Infraorbital nerve Nasopalatine and Greater palatine nerves Mandibular nerve (Cn V3) Mandibular nerve (Cn V3) The largest trigeminal division, and is both sensory and motor,exits the skull through the foramen ovale. It supplies the following structures: a. the teeth and the gums of the mandible, b. The skin in the temporal region, c. Part of the auricle including the external meatus and tympanum, d. The lower lip, e. The lower part of the face , f. The muscles of mastication, g. The mucosa of the anterior 2/3s of the tongue, h. And the mucosa of the floor of the mouth Auriculotemporal, buccal, deep temporal and masseter nerves Inferior alveolar and mental nerves Lingual nerve A head injury is any trauma resulting in injury to the scalp, skull or brain. There are five main types of head injuries: Lacerations Concussion Contusions Haemorrhage Compression Skull Fracture * * * * * * * * * * Intercranial hemorrhages. A and B. Extradural (epidural) hemorrhage. C. Dural border (subdural) hematoma. D. Subarachnoid hemorrhage. * Cranial Haemotoma Large epidural hematoma with midline shift. This is an obvious indication for operative decompression. * CT scan of a patient with a subdural hematoma. In addition, there is air in the subarachnoid space and the ventricles. In comparing the complexity of the pathology in this figure with that in previous figure. * * . a - Cutting of soft tissue б, в – clamping of vessels Stop bleeding technique * Stop bleeding from sinuses of dura mater and meningeal vessels * * * Fractures of Calvaria * Main types: Linear Depressed Comminuted Basilar The convexity of the calvaria distributes and thereby usually minimizes the effects of a blow to the head. However, hard blows in thin areas of the calvaria are likely to produce depressed fractures, in which a bone fragment is depressed inward, compressing and/or injuring the brain. Linear calvarial fractures, the most frequent type, usually occur at the point of impact, but fracture lines often radiate away from it in two or more directions. In comminuted fractures, the bone is broken into several pieces. If the area of the calvaria is thick at the site of impact, the bone may bend inward without fracturing; however, a fracture may occur some distance from the site of direct trauma where the calvaria is thinner. In a contrecoup (counterblow) fracture, no fracture occurs at the point of impact, but one occurs on the opposite side of the cranium. * SKULL BASE FRACTURES 70% of the skull base fractures occur in the anterior fossa, 20% in the middle central skull base 5% in the middle and posterior fossa. Anterior cranial fossa fracture * A patient with "raccoon eyes" and a midface fracture. Middle cranial fossa fracture BLEEDING FROM THE EXTERNAL AUDITORY MEATUS--------- A SIGN OF SKULL BASE FRACTURE BATTLE SIGN * . a - Excision of all soft nonviable tissue; б - Bones sharp edges cutting; в - Cleaning of the wound; г - Removing of all fragments of bones Craniotomy Surgeons access the cranial cavity and brain by performing a craniotomy, in which a section of the neurocranium, called a bone flap, is elevated or removed. Because the adult pericranium has poor osteogenic (bone-forming) properties, little regeneration occurs after bone loss (e.g., when pieces of bone are removed during repair of a comminuted cranial fracture). Surgically produced bone flaps are put back into place and wired to other parts of the calvaria or held in place temporarily with metal plates. Reintegration is most successful when the bone is reflected with its overlying muscle and skin, so that it retains its own blood supply during the procedure and after repositioning. If the bone flap is not replaced (i.e., a permanent plastic or metal plate replaces the flap), the procedure is called a craniectomy. * * Osteoplastic craniotomy a – cutting of the pericranium; б – sawing of the cranial bones; в – opening of the cranial cavity; г – cutting of the meningea; д – inserting of the saw under bone * * This figure indicates the optimal position for a decompressive burr hole for a presumed epidural hematoma when preoperative localization studies cannot be performed. One or more branches of the external carotid artery must usually be ligated to gain access to the skull. No attempt should be made to control intracranial hemorrhage through the burr hole. Rather, the patient's head should be wrapped with a bulky absorbent dressing and the patient then transferred to a neurosurgeon for definitive care. Decompressive craniotomy Decompressive craniotomy * * Major buttresses of the midface. Le forte lines for classifying fractures of middle third of the face Maxillar fractures * Midface maxillary fractures are usually the result of high-velocity injuries (eg, motor vehicle accidents or severe and life-threatening interpersonal traumas). The primary surgical goals in repairing maxillary fractures include restoring normal contour to the facial skeleton and restoring normal dental occlusion. Maxillary fractures were classified by Rene Le Fort. He subjected cadavers to various types of trauma and found that certain patterns of injury resulted. Le Fort divided these midface fractures into three discrete types: Le Fort I, Le Fort II, and Le Fort III. Dr. Léon-Clement Le Fort (Paris surgeon and gynecologist, 1829-1893) Le Fort Fractures Le Fort I fracture: wide variety of horizontal fractures of the maxillae, passing superior to the maxillary alveolar process (i.e., to the roots of the teeth), crossing the bony nasal septum and possibly the pterygoid plates of the sphenoid. Le Fort II fracture: passes from the posterolateral parts of the maxillary sinuses (cavities in the maxillae) superomedially through the infra-orbital foramina, lacrimals, or ethmoids to the bridge of the nose. As a result, the entire central part of the face, including the hard palate and alveolar processes, is separated from the rest of the cranium. Le Fort III fracture: horizontal fracture that passes through the superior orbital fissures and the ethmoid and nasal bones and extends laterally through the greater wings of the sphenoid and the frontozygomatic sutures. Concurrent fracturing of the zygomatic arches causes the maxillae and zygomatic bones to separate from the rest of the cranium. * A 3-D CT reconstruction showing a LeFort type 1 fracture It is also known as a Guerin fracture or 'floating palate' Mandibular fractures Fractures of mandible. Line A, Fracture of the coronoid process; line B, fracture of the neck of the mandible; line C, fracture of the angle of the mandible; line D, fracture of the body of the mandible. * * Mandibular fractures OPERATIONS ON FACE Cutting directions in the lateral part of the face * Dental Anesthesia: Types: 1. Infiltrative; 2. Conduction. * Local Infiltration of Maxillary Teeth (Incisive Fossa) * * Local Infiltration of Maxillary Teeth (Canine Ridge) Incisive and canine anesthesia * * Anterior Superior Alveolar Nerve (ASAN) and Medial Superior Alveolar Nerve (MSAN) Block (Infraorbital) Nerves Blocked: Terminal branches of the infraorbital nerve ASAN MSAN * Infraorbital Block Infraorbital Block * Tuberal Anesthesia –Posterior Superior Alveolar Nerve Block (PSAN) * PSAN Block * PSAN Block * Supplementary blocking of the greater palatine nerve * Greater Palatine Nerve Block * Greater Palatine Nerve Block * The inferior alveolar nerve block * * Inferior Alveolar Nerve Block Inferior Alveolar Nerve Block * Inferior Alveolar Nerve Block * Mental and Incisive Nerve Block * Mental and Incisive Nerve Block Nerves blocked: Mental nerve Incisive branch of the inferior alveolar nerve * Mental and Incisive Nerve Block * RECOMMENDED LITERATURE Gray’s anatomy. London, 1994. Athlas of muscle and Musculocutaneous Flaps Head and Neck Reconstruction. Arnold Mc Graw. Norfolk, Virginia, 1988. Atlas of Human Anatomy. Frank H.Netter. East Hannover, New Jersey, 1990. Clinical Anatomy by Regions. Richard Shell. New York, London, 1996. An Atlas of Surgical Anatomy. Taylor&Francis. London, New York. 2005. Atlas of Anatomy. Patrick W. Tank, Thomas R. Gest. Ann Arbor, Michigan. 2009. Clinical Anatomy. Harold Ellis. Dlackwell Publishing. London. 2006. Clinically Oriented Anatomy. Keith L. Moore, Arthur F. Dalley, Anne M.R. Agur. Lippincott Williams &Wilkisn, Philadelphis. 2010. Review of Gross Anatomy. Ben Pansky. Toledo, Ohio. 1996. Atlas of Human Anatomy. Sobotta. Munchen. Jena. 2006. Surgical Anatomy. Scandalakis. 2009. Introduction to Dental Local Anesthesia. Hans Evers, Glenn Haegerstam. 1990. UNKNOWN-0.bin