2.

4 - ANATOMY & PHYSIOLOGY OF SOFT & BONY TISSUES OF THE FACE,

Surgery BONE HEALING, FACIAL FRACTURES
Date: MAY 12, 2022

OUTLINE
I. ANATOMY & PHYSIOLOGY OF SOFT & BONY TISSUES OF THE FACE
2. BONE HEALING
3. FACIAL FRACTURES

ANATOMY & PHYSIOLOGY OF SOFT & BONY TISSUES

OF THE FACE
FACE
- Surface anatomy
○ Eyebrows - linear growth of hairs overlying the
superior orbital margin
○ Superciliary arches
○ Glabella
○ Depression in the midline at the root of the nose
→ intersection of the frontal and nasal bone
5 LAYERS OF THE FACE
(Nastaion)
○ Zygomatic arch - extends forward in front of the From superficial
ear and ends in the zygomatic bone
○ Zygomatic bone - forms the prominence of the ● skin
cheek ● subcutaneous tissue & fat
● musculo-aponeurotic
Soft Tissue Landmarks ● retaining ligaments and space
○ mimetic muscles and deep fat
compartments
● periosteum and deep fascia

SUBCUTANEOUS TISSUE & FAT COMPONENT

Compartments: superficial and deep fat compartments,
divided by mass in the face (Galea)
● Superficial fat pads - lie just deep to the skin and
serve protective functions
● Deep fat pads functions:
○ mechanical support
○ volume of the face

Different names:
SUPERFICIAL MUSCULOAPUNEUROTIC SYSTEM
● Organized fibrous network
● Connects the fatal muscles to the dermis
● Provides definition of facial expressions
● Complex network of layers of connective tissue that
envelops and joins the skeletal muscle of the face
● Very important surgically as a key target in face
lifting and functionally as a distributor of facial
expression
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● This mass extends from the Galea aponeurotica
from the forehead down to the neck as the
Platysma and is connected to the dermis via the
vertical septae
● Galea in the forehead
● Temporoparietal fascia in the temple
● SMAS in the face itself
● Platysma in the neck
RETAINING LIGAMENTS
● Firmer condensations of fibrous connective tissue,
located in constant anatomic locations and separate
facial planes and compartments
● Strong and deep fibrous attachments that originate
from the periosteum or the deep facial fascia and
travel perpendicularly through the fascial layers to
insert onto the dermis
● Various ligaments act as an anchor points, retaining
and stabilizing the skin and superficial fascia
through the underlying deep fascia and facial
skeleton in defined anatomic locations
○ very important targets in surgery
 NEUROVASCULAR SUPPLY OF THE FACE

● Tissue of the face is richly vascular and are liberally

supplied with blood vessels in all parts
● Arterial supply of the face - comes from an
extensive anastomoses from the branches of the OTHER BRANCHES OF THE FACIAL ARTERY
external and internal carotid artery - Superior and Inferior Labial artery
● Facial artery - chief artery that supplies blood to the - Angular artery
o terminal part of the facial artery which runs
structures of the face which arises from the external
alongside the nose towards the medial angle of
carotid artery
the eye
○ reaches the face by piercing the deep
OTHER BRANCHES OF THE EXTERNAL CAROTID
fascia at the lower border of the mandible
ARTERY
and then curving up to the face close to - Superficial temporal artery
the anterior border of the masseter - Transverse facial artery
- Internal maxillary artery
o terminal artery → infraorbital artery (enters the
face via the infraorbital foramen)
▪ infraorbital artery supplies the
infraorbital region in the lower eyelid
with possible anastomoses with the
facial artery
OTHER BRANCHES OF THE INTERNAL CAROTID
ARTERY
- Supratrochlear artery
- Supraorbital artery
o Branches of the ophthalmic artery
▪ Branch of the ICA
o supplies the skin of the forehead
ANASTOMOSES

● Anastomoses of the arteries in the face provide an

important portion of the collateral circulation
available when other vessels are compromised
VENOUS DRAINAGE

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 ● Facial nerve is the motor supply of the muscle facial
expression

Motor

● The superficial veins of the face drain into the ● posterior belly of digastric
external and internal jugular vein ● stylohyoid muscle
● The facial vein is the major vein draining the face ● stapedius
and it begins at the angular vein at the middle angle ● muscles of facial expression
of the eye
Sensory

● taste for anterior ⅔ of tongue

● Sensation to:
○ external auditory canal
○ concha
○ earlobe

Parasympathetic

● lacrimation
● salivation

● The facial vein receives tributaries that corresponds

to the branches of the facial artery

NERVE SUPPLY OF THE FACE

● Facial nerve emerges from the stylomastoid

foramen to enter the parotid gland
● does not supply the skin
● Has 5 terminal branches
○ Temporal
○ Zygomatic
○ Buccal
● Skin of face - supplied by the branches of the
○ Mandibular
trigeminal nerve except the area of the angle of the
○ Cervical
mandible and the parotid gland which is supplied by
the cervical plexus FACIAL BONES (14)

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 SECTIONS OF THE FACE
HORIZONTAL BUTTRESS
less well known than the vertical buttress, serve to impart
cross member stability to the facial skeleton and define the
anteroposterior, as well as the horizontal dimension of the
face

● Frontal bar
● Infraorbital rim
● Maxilla
● Mandible

● Upper third
○ frontal bones
● Middle third
○ maxilla, zygomas and the orbits
○ nose and nasoethmoidal complex
● Lower third
○ mandible

BIOMECHANICS OF THE CRANIO-MAXILLOFACIAL

SKELETON
The CMF provides a frame for the protection of the soft
organs and forms a bony structurally stable frame, the
supporting bony structure of the base can be conceptualized
at the system of the vertical and horizontal buttresses
● The arch of the hard palate and the arch of the
VERTICAL BUTTRESS mandible form the horizontal facial buttress which
are important in defining the width of the lower third
Provide the bony support for mastication
of the face and the occlusal arch
● Nasomaxillary ● Located within the compartmental system are the
● Zygomaticomaxillary several buttresses which can tolerate higher forces
○ referred to as the key ridge that transfers
the majority of the masticatory force MANDIBLE
● Pterygomaxillary

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 ● hinged to the skull base in two bilaterally symmetric
attachments that occurs at a temporomandibular LOCATION OF STRESS
joint - vary depending on the load bite location
○ TMJ - true diarthrodial joints that both
swing and slide

● load posterior to the fracture side will result in

compression at the superior margin and tension at
the inferior margin and loads when biting

BONE HEALING
BONE ANATOMY
● Cortical - Compact Bone
○ Peripheral Cortex
Horizontal mandible ○ Packed osteons and Haversian Systems
● Cancellous - Spongy bone
● Alveolar bone - tooth bearing bone ○ Medullary
● Basal bone ○ Network of trabeculae
○ Contains Bone Marrow
Vertical mandible

● Angle
● Ramus
● Condylar process
● Coronoid process

● Cellular
● Canine tooth - contralateral canine – is the ○ Osteoblast
symphyseal region (divided into: symphysis in the ○ Osteoclast
midline and parasymphyseal region) ○ Osteocyte
● Canine to the angle of the mandible - body of the ● Organic
mandible ○ 90% collagen type 1
○ 10% non collagenous proteins and lipids
OCCLUSION
● Inorganic - 65%
○ Hydroxyapatite - Major Component
Angle 1: (Class of occlusion 1) → Normal molar relationship
has been identified by angle as the mesiobuccal cusp of the ○ Calcium
maxillary first molar fitting within the mesiobuccal groove of ○ Phosphorus
the mandibular first molar
BONE REMODELING
● All bones are in a state of constant turnover.
● Bone is constantly being removed and replaced
● Liberates calcium into the bloodstream

Class 2 occlusion- when maxillary molar is more anterior

Class 3 occlusion- when maxillary molar is more posterior

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OSTEOBLAST

FRACTURE
● From the Latin word “Frangere” meaning “To Break”
● Break in the structural continuity of Bone - Mathog

● New bone formation

● Derived from mesenchymal precursors
● Line the surface of the bone and produce osteoid
● have receptors for the parathyroid hormone,
prostaglandins, Vitamin D, and Certain Cytokines
● Synthesize bone matrix
● Regulate its mineralization by capturing calcium
ions from the bloodstream

OSTEOCLAST

BONE HEALING
● BONE HEALING
○ Primary
○ Secondary

● Cells that removes the bone

● Derived from the hematopoietic stem cells
(monocyte precursor cells)
● Multinucleated cells whose function is bone
resorption pits
○ Howship’s Lacunae

OSTEOBLAST → OSTEOCYTES (cells of mature bone PRIMARY BONE HEALING

tissue)
● interfragmentary motion completely avoided
● Osteoblasts surrounded by bone matrix ● intracortical remodeling, inside and in between the
○ trapped in lacunae fragment ends
● Function poorly understood ● Direct Bony Bridging
○ regulating bone metabolism in response to ● Deposition of lamellar bone parallel to long axes of
stress and strain bone

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SECONDARY BONE HEALING REMODELING
● Excess material removed
● Gap
● Compact bone is laid down
● Interruption of circulation of larger vessels
○ Woven bone → lamellar Bone
● Resorption at fracture ends
○ Cutter cones
■ osteoclasts
■ osteoblasts

GRANULATION: Soft Callus Formation (2-3 weeks)

● Capillary ingrowth → Increased vascularity

● Proliferative Phase: Fibroblasts
● Granulation Tissue
● Fibrocartilaginous Callus Forms replaces the ● Prerequisites for Bone Healing
hematoma ○ Sufficient blood supply
○ Presence of specific cells
○ Adequate mechanical stability
● Factors affecting Bone healing
○ Local
■ Open or Closed
■ Infection
■ Segmental or Comminuted
■ Fixation, Stabilization,
Immobilization
■ Irradiation
○ Systemic
● Complications in Bone healing
○ Malunion
GRANULATION: Hard Callus Formation (3-4 weeks) ■ Healed with fragments not in
anatomical position
● Consolidation ■ caused by:
● Begins 3-4 weeks after injury until 2-3 months late ● inaccurate reduction
● Endochondral Ossification ● ineffective
○ New bone trabeculae immobilization
○ Fibrocartilaginous callus converts to bony
callus care of OSTEOBLASTS

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 ●
○ Delayed union
■ Healing has not advanced at the
average rate (3-6 months)
■ Treatment is prolonged
immobilization (4-12 weeks)

■
○ Non-union
■ Established when a minimum of 9
months has elapsed since
fracture with no visible
progressive signs of healing for 3
months
■ Biological factors - unfavorable
vascularization, infection

● TORUS FRACTURE
○ Usually in shaft of a long bone that is
characterized by bulging of the cortex
○ trabecular compression
● GREENSTICK FRACTURE
■ ○ bending of the bone such that the
● Summary structural integrity of the convex surface is
○ Bone has different composition, each with overcome
its own importance ○ concave surface remains intact
○ Fracture immobilization is key for adequate
bone healing

EVALUATION AND ASSESSMENT IN FACIAL FRACTURES

ETIOLOGY
● MVA - most common cause
● Assault
● Fall
● Sports
● Industrial

FRACTURE CLASSIFICATION
● Open vs Closed
● Complete vs Incomplete
● Simple
● Comminuted
● Displaced vs Non-Displaced

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 EVALUATION OF FRACTURES: UPPER & MIDFACE
REGION

● Signs & Symptoms:

EVALUATION OF FRACTURES ○ Skeletal Deformities
ANATOMY ■ Facial asymmetry
■ Depressed Malar prominence and
● 4 Facial Units zygomatic arch
○ Upper Face (Frontal) ■ Step and gap deformities
○ Upper Midface ○ Ocular Symptoms
○ Lower Midface (Occlusal) ■ Periorbital edema/hematoma
○ Mandibular Units ■ Pseudoptosis
■ Increased Scleral Show
■ Subconjunctival ecchymosis
■ Pupillary disparity
■ Diplopia
■ Enophthalmos
■ Exophthalmos
○ Nasal Symptoms
■ Epistaxis
■ Hemosinus
■ Septal Deviation
■ Septal Hematoma
○ Oral Symptoms
■ palpable contour disturbance of
the ZM buttress
■ restriction of mandibular opening
or closing: Malocclusion and
Trismus
● FORCES NEEDED TO FRACTURE EACH
■ ecchymosis of the gingivobuccal
SEGMENTS:
maxillary sulcus
○ Sensory Impairments
■ Infraorbital Nerve
■ Zygomatic Nerve
■ Zygomaticotemporal Nerve
● PHYSICAL EXAMINATION
○ Palpation for Gross and Step-off
Deformities
○ Drawer’s sign
○ racoon’s eye
○ battle sign

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 ○ Visual acuity
○ ocular reflex
○ extraocular muscle movement

● IMAGING
○ Water’s view
○ Submentovertex View
○ Caldwell’s View
○ Facial CT-Scan (Gold Standard)

FRACTURE CLASSIFICATION

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 ■ infraorbital rim
■ zygomatic arch
■ lateral orbital wall

● NASO-ORBITO-ETHMOIDAL FRACTURES
○ Nasal bones
○ Septum
○ Frontal bone
○ Nasal process of maxilla
○ Lamina papyracea
● NASAL BONE FRACTURES

EVALUATION OF FRACTURES: LOWER FACE/

MANDIBULAR UNIT
● TREATMENT OBJECTIVES
○ aesthetic
○ Functional
■ Proper Occlusion
■ Mastication
● 200-300N Incisors
● 300-500N Premolars
● 500-700N Molars
● CLINICAL ASSESSMENT
○ Physical Exam
■ Spatula Test
■ Occlusion
■ Deformities
● LE FORT FRACTURE ● Step
● Crossbite
● Open Bite

● ORBITOZYGOMATICOMAXILLARY COMPLEX
FRACTURES
○ Five articulations:
■ Frontal process
■ zygomaticomaxillary buttress

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 ■
○ Multifragmentary Mandible Fractures
■ Comminuted Fractures

● IMAGING
○ Panoramic X-ray
○ Mandible AP/OL
○ High Towne’s View
○ CT Scan

■
○ Defect Mandibular Fractures
■ Bone loss creates a “Gap”

■
○ Infected Mandibular Fractures
■ from untreated open fractures

● CLASSIFICATION:
○ Simple
■ Linear
■ Single Fracture Line
○ Complex
■ Comminuted
■ Sagittal ■
■ Multiple ● Summary
■ Edentuluos ○ Clinical assessment is important
○ Imaging confirms fracture diagnosis
COMPLEX MANDIBULAR FRACTURES ○ There are various classification schemes
● Fractures in bones with reduced Bone Quality in diagnosing facial fractures.
○ Atrophic Mandible
■ alveolar process and often much
THE ART OF PLATING IN FACIAL FRACTURES,
of the basilar bone has been lost
OSTEOTOMIES AND RECONSTRUCTION
MANDIBLE
- u shaped bone
- only mobile bone of the Facial/ Cranial region
- Bilateral joint articulation
- thick cortical bone with single vessel for endosteal
blood supply

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 - Blood supply varies with patient’s age and amount
of dentition
- w/ atrophic mandibles, endosteal blood supply is
decreased and periosteal blood supply is dominant

BIOMECHANIC OF MANDIBLE
- bite & muscular forces applied to the mandible
determine zones of tension and compression
- Tension zone
- Alveolar portion of the mandible
- Compression zone
- Basal portion of the mandible

- only simple fx can provide bone buttressing

- bone shares the load with the plate
- u-shaped bone that deforms with movement based - champys miniplate fixation along the ideal line of
on the origin and insertion of the muscles of osteosynthesis
mastication

MUSCLE ACTION CLASSIFICATION

- Generally apply to Angle and Body fx
- Based on direction of muscle pull
- Anterior group- downward, backward,
medial pull
- Posterior group - upward, forward, medial
pull
- Ex vertically favorable and Non favorable -
resistance to medial pull
- Horizontal favorable vs. Non favorable -
resistance to upward pull

HUNTING BOW CONCEPT

- Similar to hunting bow shape
- Strongest in the midline (symphysis) and weakest at
both ends (condyles). Most common area of fx →
condylar region
- force is transmitted from the body of the mandible of
the condyle
- blow to the ipsilateral mandible → contralateral fx
(condylar region)
- if impact is in the midline of the mandible, fx of the
bilateral condylar region are very common - affected bone area is not able to share any load
with the implant
- implant assumes the functional load entirely
IDEAL LINE OF OSTEOSYNTHESIS
- reconstruction plate is required
- champy concept of miniplate osteosynthesis in - Complex fx requiring load bearing fixation:
simple fx - Comminuted/ defect fx
- consider the position of the inferior alveolar nerve - Chronically infected fx
- Fx in the atrophic mandible

IMAGING MODALITIES FOR MANDIBULAR FXS

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 - orthopantomogram & PA plain films may be
sufficient for simple fx lines

METHODS OF MMF
- Attached to/between teeth:
- Arch bars
- many different types
- CT scan (gold standard)
- Ivy loops/eyelet wires
- CT scan in axial & coronal views provide additional
- Embrasure wires
information

- ideally need 2 radiographic views of the fx that

orients 90 degrees from one another to properly
work up features - attached to underlying bones
- Panoramic & Towne’s view - IMF screws
- CT scan Axial & Coronal view - hybrid

ESTABLISHING THE PRE TRAUMATIC OCCLUSION

- Restoration of the occlusion:
- Intraoperative/postoperative
maxillomandibular fixation (MMF)

MALOCCLUSION

- MMF can be achieved with wires/ elastics

TO FIGURE OUT MALOCCLUSION

- find someone who can
- stop and get some study models

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 IMPLANTS

SURGICAL APPROACHES TO THE MANDIBLE
● A large variety of plates are available for application
to the mandible.
● Types of plates include:
○ Mandible plates 2.0
○ Locking plates 2.0
○ (Locking) reconstruction plates
○ Dynamic compression plates
○ Universal fracture plates

- rigid fixation
- when screws engage plate, they impart
compression across the fx segments
- results in the fragments being brought together with
compression and interfragmentary friction

- rigid fixation technique

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 - large plates that are load bearing (can bear entire - screw must be placed perpendicular to
load of region) fracture
- consist of plates that utilize screws greater than 2 - technique sensitive
mm in diameter (2.3, 2.4, 2.7, 3.0)
- can use non-locking and locking type plates
- must use 3 screws on each side of fx (max strength
w/ 4)

MANDIBULAR FX

SCREWS

2 TYPES

- Self-tapping
- Self- drilling (don't need instrumentation, might lead
to misalignment)

ORIF
- any form of fixation that counters any biomechanical
forces that are acting upn the fx site
- prevennts any interfragmentary motion across that
fx site
- heals with primary (contact/gap) bone healing,
produces no callus around the fx site
- eg. cmpression plates (DCP/EDCP), reconstruction
plates with screws

LAG SCREW TECHNIQUE

- utilizes screws that create a compression of the fx
segments by only engaging the screw threads in the
remote segment and screw head in the near cortex
- rigid fixation
- advantages:
- low cost, less equipment
- faster technique than plating
- rigid fixation
- disadvantages:

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 CONDYLAR FX

- ORIF
- Choice of fixation
- one plate (larger)
- two plates
- hybrid plate

FX OF EDENTOUS MANDIBLE
TREATMENT
- Closed reduction - circummandibular wires and
circumzygomatic wires with dentures or splint
- IMF for 6-8 weeks
- used in Mild Atrophy
- Severe:
- ORIF
- Rigid fixation w/ reconstruction plate

MIDFACE AND UPPER FACIAL SKELETON

SURGICAL APPROACHES
INCISIONS

- Coronal
- access to upper & middle third
- beveling knife may reduce scar alopecia
- subgaleal dissection
- incise periosteum 2.5 cm above the
supraorbital rim
- alternatively, may raise pericranial flap
- Upper eyelid
- allows exposure and repair of
- ZF suture
- lateral orbital wall
- lateral canthus
- Lower eyelid
- allow exposure to:
- infraorbital rim
- zygomatic body
- orbital floor
- all incisions follow:
- preseptal dissection
- minimizing injury to orbital fat
- reducing scarring of septum
- Vestibular (upper buccal sulcus)
- incision is at least 5 mm above attached
gingiva to allow for closure

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 - Existing lacerations FIXATION OF LE FORT II & III
- Lateral Dissection
- coronal approach may be necessary
- facial nerve branches lie just above the
- expose fx at frontonasal region for fixation
superficial leaf of the deep temporal fascia
- Transconjunctival incision AFTER INTERNAL FIXATION
- medial & lateral extensions
- MMF is released and occlusion checked
MAXILLARY FRACTURES
BIOMECHANICS PALATAL FX
- vertical and horizontal buttresses - directly plate the fx intraorally

CLASSIFICATION

LE FORT I ISOLATED ZYGOMATIC ARCH

- close reduction technique
- low level/ Guerin fracture - incision: temporal area
- open technique
LE FORT II

- pyramidal fracture, subzygomatic fracture

LE FORT III

- craniofacial dysfunction, high transverse, supra

zygomatic

REDUCTION

- maxillary fracture disimpacted with Rowe forceps

- maxilla - mandible fixation applied
- ensure condyles are properly seated in glenoid
fossa

FIXATION OF LE FORT I
- maxillary buttresses exposed by upper sulcus
incision
- fractured buttresses plated
- at least 2 screws on each side of the fx ORBITAL WALL FX
DIAGNOSTIC EVALUATION

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 - CT scan
- Forced duction test
- To assess preoperative entrapment and
post reconstruction mobility

PATIENT EVALUATION
- Physical
- Extraocular motility (EOM)
- Visual acuity
- Ophthalmology consultation for all:
- Preoperative and postoperative
- Up to 40% of patients have associated
injury

DIAGNOSTIC IMAGING - CT SCAN

- Axial cuts identify:
- Lateral and medial wall fracture
- Medial and lateral rectus shape
- Coronal cuts
- Floor and medial wall fractures
MANAGEMENT OF TYPES I & II
- Measure floor fracture size
- Inferior and medial rectus shape - Medial canthus is often still attached to the central
- Sagittal cuts fragment
- Floor shape - Approaches include upper vestibular and lower
- Fracture extent eyelid with:
- Fracture position - Coronal vs existing lacerations vs direct
- Inferior and superior rectus shape - Plate bone pieces (stable - unstable)
- Consider nasal dorsum support
ORBIT CORRECTION PRINCIPLE - Depends on septal and mid vault nasal
support
- must get the rims right first (ie ORIF, NOE and
- Can occur with ZMC fx
ZMC) and then correct the walls
MANAGEMENT OF TYPES III
NASOETHMOIDAL FX
EXAMINATION - Bone plating
- May need to reconstruct medial orbota wall
- Glabella exam
- Bone graft to nasal dorsum for septal and nasal soft
- Telecanthus
tissue support
- “Bow- string” or lid traction test
- Transnasal wiring of medial canthus to reattach
- Bimanual test
bone
- Soft tissue splinting:
TELECANTHUS DEFORMITY - Reduces swelling postoperatively
- Lateral displacement of the medical canthal tendon - Shapes soft tissue
- Rounding of the medial palpebral fissure
- Widening of the NOE/ nasal dorsum MEDIAL CANTHOPEXY TECHNIQUE
- Transverse shortening of the palepebral fissure
- many fixation techniques
- tighten the transnasal wires and medial canthi last
to ensure proper positioning

FRONTAL SINUS FX
PRINCIPLE

GOAL

- create a safe sinus

- restore facial contour
- avoid shorthand long term complications

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 - correct malocclusion
- facial asymmetry
- obstructive sleep apnea
- maxillary atrophy
- access to tumors posterior to maxilla

MAXILLARY WING PROCEDURE

- Tumor resection located medial infra fossa,

pterygomaxillary region, lateral wall of nasopharynx

MANDIBULOTOMY

TRANSPALATAL OSTEOTOMY APPROACH

MAXILLECTOMY

References:
REDUCTION

- simple
- comminuted
- fixation

PANFACIAL FX
- fracture of 2 or more of the facial units
- Goal of tx:
- Principles of repair
- Sequencing is a major challenge
- 2 options:
- bottom to top
- top to bottom
- End at Le Fort Level I
- Restore the anatomy to achieve proper
facial width, height and projection

BOTTOM TO TOP SEQUENCING

- fix mandible
- reestablish maxillo mandibular unit first
- then start from calvarium and end at Le Fort level I

MAXILLOMANDIBULAR UNIT
- Condylar Fx - restore proper mandibular height and
chin positiom
- Palatal split - restore facial width and occlusion

TOP - DOWN SEQUENCING

- reduction and fixation at level of calvarium first
- then reestablish maxillomandibular unit and fix
mandible and end at Le Fort I level
- Reestablish midfacial buttresses
- start on side with least comminution
- Zygoma - restore facial width and projection
- NOE fractures - restore facial projection and
intercanthal distance
- Condylar fx- restore proper mandibular height and
chin position
- Palatal split - restore facial width and occlusion

OSTEOTOMIES
LE FORT I OSTEOTOMY

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