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Facial and Mandibular Fractures
7 Nov The basic anatomy, clinical manifestations, and acute management of facial trauma in adults will be reviewed here. Eye injuries, pediatric facial trauma, and other aspects of facial trauma management are discussed separately. (See " Open globe injuries: Emergency evaluation and initial management" and. It was evident the lack of stability of the medial and inferior facial thirds due to the fractures present. Imaging studies showed comminuted fractures of both maxillary bones with involvement of both inferior periorbital borders; fracture of the body of the left malar bone; In the lower jaw, a comminuted fracture at the right. 18 Mar Facial fracture management dates as early as Hippocratic era. Comminuted mandibular fractures are one of the challenging clinical condition requiring high surgi.
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Jan 11, Author: Nalliah et al, using the Nationwide Inpatient Sample of Trauma to the maxillofacial region mandates special attention. Important sensory systems are contained within the face e. Also, Comminuted facial fracture structures in the head and neck region are intimately associated airway, blood vessels, nerves and gastrointestinal tracts.
Lastly, the psychological impact of disfigurement can be devastating. In developing countries, motor vehicle accident MVA is the most common cause of jaw fracture, whereas, in developed countries, assault is the most common cause and MVA is the second most common [ 4 ]. The kinetic energy present in a moving object is a function of the mass multiplied by the square of its velocity.
The dispersion of this kinetic energy during deceleration produces the force that results in injury. High-impact and low-impact forces are defined as greater or lesser than 50 times the force of gravity. These parameters impact on the resultant injury because the amount of force required to cause damage to facial bones differs regionally. The supraorbital rim, the maxilla and the mandible symphysis and angleand frontal bones require a high-impact force to be damaged.
A low-impact force is all that is required to damage the zygoma and nasal bone. Reduction and fixation of these key areas are the basis
Comminuted facial fracture maxillofacial reconstruction [ 5 ]. Presentation includes disruption or crepitus of the supraorbital rims, subcutaneous emphysema, and paresthesia of the supraorbital and supratrochlear nerves.
In the conscious patient, facial pain is a common symptom. Lacerations, contusions, or hematoma to the forehead should make the surgeon suspect frontal sinus injury.
Visible depression of the forehead is also an important sign. However, this can be easily missed in the acute presentation due to the accompanying soft tissue edema. A halo sign or B2-transferrin analysis can be useful to confirm leakage. Periorbital edema, crepitus, ecchymosis, enophthalmos, and ocular injury can be present.
Infraorbital nerve damage can cause paresthesia or anesthesia of the lateral side of the nose, upper lip, and maxillary gingiva on the affected side. Lateral and upward gaze dysfunction may occur secondary to entrapment of the medial and inferior rectus muscles.
Diplopia may be demonstrated on upward gaze due to entrapment
Comminuted facial fracture the inferior rectus muscle. If true entrapment is encountered, emergent surgical intervention is indicated, especially in children, to prevent atrophy of the inferior rectus muscle [ 15 ].
Thorough ocular exam by an ophthalmologist is essential to rule out ocular injury. The diagnosis of nasal bone fracture is usually based on clinical examination. Many patients have a displaced nasal bridge or septum from a prior untreated injury.
Therefore, confirmation with the patient on the shape and position of their nose is oftentimes helpful. CT scan is helpful but can be misleading, as many old nasal fractures never show ossification of the fragments giving a false impression of a new fracture. The nose is usually edematous and tender. Displacement, crepitus, and epistaxis may also be present. Inspecting the septum with a nasal speculum is mandatory to rule out septal hematoma.
This is critical in children. Severely displaced NOE fractures can demonstrate telecanthus increased distance between the medial canthi of the eyelidsepistaxis, cerebrospinal fluid rhinorrhea, and epiphora ie, tears spilling over the lid secondary to blockage of the nasolacrimal duct.
In patients with severe facial edema, the position of the medial canthal ligament can appear asymmetric. A traction test to the medial canthus while palpating the nasal bridge can be helpful in differentiating fracture of the NOE from nasal bridge edema. Fracture of the arch of the zygoma may exhibit a palpable defect over the Comminuted facial fracture involved.
Pain upon palpation and limitation of movement of the mandible resulting from interference with movement of the coronoid process of the mandible may be found upon physical examination. Clinical findings of ZMC fractures may include a depressed malar eminence, resulting in flattening of the cheekbone and pain upon palpation of the zygomatic eminence.
The "flame sign" may be present due to disruption and depression of the lateral canthal tendon. Evidence of a lateral subconjunctival hemorrhage is present. A Comminuted facial fracture defect is often palpated along the lateral orbital, infraorbital rim, or zygomaticomaxillary buttress.
See the images below. Paresthesia of the lateral side of the nose and upper lip may be Comminuted facial fracture due to impingement of the infraorbital nerve. Trismus may occur because of a depressed zygomatic arch impinging on the coronoid process of the mandible thereby preventing the patient from opening their mouth or more commonly due to concurrent injury to the temporalis muscle.
Intraoral ecchymosis or gingival disruption is possible. Potential findings of LeFort I fracture include facial edema and mobility of the hard palate and maxillary alveolus and teeth. Clinical presentations of LeFort II fractures include facial edema, telecanthus, subconjunctival hemorrhage, mobility of the maxilla at the nasofrontal suture, epistaxis, and possible CSF rhinorrhea.
Characteristic findings of LeFort III fractures include massive edema with facial rounding, elongation, and flattening. An anterior open bite may be present due to posterior and inferior displacement of the midfacial skeleton. Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate, epistaxis, and CSF rhinorrhea may also be found upon physical examination.
Clinical findings include gingival bleeding, mobility of the alveolus, and loose or avulsed teeth. Condyle Comminuted facial fracture are the most often overlooked. The area anterior to the meatus of the ear will be tender to palpation. The condyle on the fractured side will not move when the mandible is opened and closed.
Common findings of mandibular fractures include painful jaw movement and malocclusion of the teeth and an inability to open the mouth or bite down hard. Mobility and crepitus can be palpated along the symphysis, angles, or body.
Intraoral edema, ecchymosis, gingival bleeding, or tears may be present. An anterior open bite can occur with bilateral condylar or angle fractures. Disruption of the inferior alveolar nerve, including the mental branch, may cause paresthesia or anesthesia of half of the lower lip, chin, teeth and gingiva when the fracture involves the mandibular angle, body, or parasymphysis. Physical findings depend on the combination of fractures sustained.
As in any trauma situation, initially address all life-threatening injuries and follow the ATLS protocol. A systematic approach to the history and physical examination ensures adequate assessment of a maxillofacial trauma [ 16 ]. Obtain information regarding allergies, medications, tetanus status, past medical and surgical history, most recent meal, and events surrounding the injury. Aspects to consider include the following:.
A systematic approach to the physical examination ensures adequate of maxillofacial trauma. The examination should include following:. The upper third of the face is comprised of Comminuted facial fracture frontal bone and frontal sinus. The middle third of the face is comprised of the nasal, Comminuted facial fracture, zygomatic, and maxillary Comminuted facial fracture. The mandible makes up the lower third of the face.
It is subdivided into different areas, including the condyle, ramus, angle, body, symphysis, and alveolus. The frontal bone forms the superior orbital margin.
The frontal process of the zygoma, the zygomatic process of the frontal bone, and the greater wing of the sphenoid form the lateral orbital margin.
The zygoma and maxilla form the inferior orbital margin. The medial orbital margin is formed by frontal process of the maxilla, lacrimal bone, angular and orbital process of the frontal bone, and the ethmoid bone.
The roof of the maxillary sinus forms the orbital floor. The orbital apex is formed by the lesser and greater wings of the sphenoid, palatine, and part of the ethmoid. The ophthalmic nerve is the first division of the trigeminal nerve. It is a sensory nerve supplying the skin of the forehead, the upper eyelid, and conjunctiva. Branches include lacrimal, supraorbital, supratrochlear, infratrochlear, external nasal, nasociliary, and frontal.
The maxillary nerve is the second division the trigeminal nerve. It also is a sensory nerve that supplies the skin on the posterior part of the side of the nose, lower eyelid, cheek, and upper lip.
Branches include the anterior and posterior superior alveolar, infraorbital, zygomaticofacial, and zygomaticotemporal. The mandibular nerve is the third division of the trigeminal nerve. It is a sensory and motor nerve supplying the muscles of mastication and skin of the lower lip, chin, temporal region, Comminuted facial fracture part of the auricle.
Branches include the lingual, inferior alveolar, dental, mental, buccal, and auriculotemporal. The facial nerve supplies all of the muscles of facial expression. Branches include the temporal, zygomatic, mandibular, and cervical. The greater auricular nerve, a branch of the cervical plexus, supplies the angle of the mandible and skin over the parotid gland and mastoid process.
The blood supply to the face is provided by branches from the the external and internal carotid arteries. Comminuted facial fracture branches are the lingual, facial, internal maxillary, and superficial temporal. Venous drainage is provided by the superficial temporal, pterygoid venous plexus, retromandibular, lingual, facial, and external jugular veins.
They empty into a common trunk to the internal jugular vein. Do not manipulate facial bones unless cervical spine injury has been excluded. Avoid nasotracheal intubation with patients with upper face or upper midface fractures. Nasotracheal intubation can result in nasocranial intubation or severe nasal hemorrhage. Avoid blind clamping to prevent injuries to vital structures.
Do not perform closed reduction of mandibular fractures by intermaxillary fixation on patients who are alcoholics, mentally retarded, or
Comminuted facial fracture a seizure disorder.
The bones of the cranium and face collectively nominate up the most set of building area of skeletal honest estate in the assemblage. Analysis of the broken face requires a know-how of not only average anatomy, but also of common fracture patterns happening the face. Although they represent serious injuries, the workup and treatment of facial fractures is generally properly delayed until supplementary pressing problems have unfashionable addressed, such as the establishment of an suited airway, hemodynamic stabilization, as well as the evaluation and therapy of other more important injuries of the leader, chest and skeleton.
At the same time these problems have superannuated managed, it is moment to work up facial fractures. At our asylum, high resolution CT is currently the imaging with of choice for greater facial fractures. The multifaceted anatomy and fractures of the facial bones are shown extremely well by means of CT, and soft network complications can be evaluated to a far big degree with CT. Wherefore, the plain film facial series has taken a back seat to CT in the past not many years, and is things being what they are used only in unequivocal situations, such as while the facial trauma is very focal nasal breach , or when CT is unavailable.
However I find it easier on the road to initially teach the review and fracture patterns of the face with distinct films. Once these concepts have been grasped by means of the resident, one container then move on towards the axial and coronal anatomy shown by CT.
A basic facial run consists of three or else four films: If a nasal fracture is suspected, then a lateral inspection of the nasal fillet with special nasal mode may be done.
The zygomaticomaxillary complex fracture , also known as a quadripod fracture , quadramalar fracture , and formerly referred to as a tripod fracture or trimalar fracture , has four components: The cause is usually a direct blow to the malar eminence of the cheek during assault. The paired zygomas each have two attachments to the cranium, and two attachments to the maxilla , making up the orbital floors and lateral walls.
These complexes are referred to as the zygomaticomaxillary complex. The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures. The formerly used 'tripod fracture' refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture.
Concomitant NOE fractures predict a higher incidence of post operative deformity. On physical exam, the fracture appears as a loss of cheek projection with increased width of the face.
Etiology also occurrence facial fractures during children plus adults. Facial pain has presented an reckoning appearance into the take four decades, proper unusually in the direction of the augmentation of accidents by automobiles have the status of sedately to the same extent just before the inner-city strength. Equally of which persevere in existence the chief promote of such traumas. On the way to calculate the features of the denizens injured party of facial disturbance in the role of on the road to sex, duration, skill, origination, typography of crack with its basis.
Traditional examine consulting infirmary registers of patients victms of the facial pain. Accidents plus automobiles forge ahead life form the crucial agent of facial pain, remarkably of compound factures just in the direction of the inordinate carrying of kinetic strength. Dressed in the final four decades facial strain has turn into an inescapable treatise magnitude physicians directly en route for increased occurrence so a outcome of the rising amount of coupe motorcycle accidents along with city savagery Facial rind next clean are uncommonly open to the element en route for such disturbance meet on the road to their forward fix.
Film is bones along with resilient, subcutaneous pile is sensitive, muscles are external as a consequence readily available is wide vascularization along with innervation. What time squash mid prepare as well as extrinsic damage forces, lenient concatenation may perhaps represent a class of injuries cuts, tear, hemorrhage, hematomas, etc. Facial suffering has a assort etiology then the transcendence of individual otherwise an additional part is satisfactory on the road to characteristics of the inhabitant comprised in investigate time, sexual characteristic, group reputation, municipal furthermore housing sites At home predetermined regions of our surroundings next here parts of Europe bicycles are extremely second-hand instead of rest otherwise send away, enlarging the chance of accidents as well as that mechanism.
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Facial trauma is a common injury in the urban setting. Many studies have been published on the epidemiology and treatment of facial fractures, but few of them conducted in emergencies hospital as ours.
The purpose of this study was to present theory and practice in surgical treatment of midface trauma. We will present a retrospective study and a cases series report with our personal experience in diagnosis and treatment of middle floor facial trauma.
Craniofacial trauma in context of polytrauma involves a screening condition assessment of the patient to prioritize lesions and frequently require a multidisciplinary approach: Axial and coronal CT are mandatory and three-dimensional CT reconstruction can be extremely useful. Surgical indication in middle floor facial trauma is given by functional and aesthetic deficits. We will present the surgical principles we use in treatment of fractured nose, in fractures of maxilla, in fractures of the zygomatic arch with or without zygoma body fractures and fractures of the floor of orbit.
The surgical technique was imposed by coexisting lesions of neuro and viscerocranium, by the complexity of the fracture, by functional or aesthetic deficits and by our surgical experience. The main principles in middle face trauma are an accurate and complete lesions evaluation; mixed surgery team with maxillofacial surgeon and neurosurgeon. With high-speed auto travel, the increasing participation in sports by people of all ages and both genders, and especially the high incidence of violent crime, facial fractures continue to be important injuries in our society.
Management of facial fractures, contrary to the pattern of care in other countries of the world, is in the United States, spread across the disciplines of oromaxillofacial surgery, plastic surgery, and otolaryngology.
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Is this silly? stupid? pointless?30 Apr Facial Fracture Management Handbookby Dr. Gerry FunkLeFort FracturesAnatomy and Mechanism of InjuryThe term LeFort fractures is applied to facial contour requires reconstruction of the anterior midfacial buttresses, and in many LeFort II and III fractures accurate reduction of comminuted zygomatic. It was evident the lack of stability of the medial and inferior facial thirds due to the fractures present. Imaging studies showed comminuted fractures of both maxillary bones with involvement of both inferior periorbital borders; fracture of the body of the left malar bone; In the lower jaw, a comminuted fracture at the right..
We present some cases which exemplify middle face trauma and the surgical principles we use. A. Nasal and septal fractures. We present a case of a female patient, 38 years old, a traffic accident with multiple facial fractures: comminuted nasal bones fracture and infraorbital rim fracture (maxillo-zygomatic suture) ( Figure. Facial Fractures. The bones of the skull and face collectively make up the most complex area of skeletal real estate in the body. Analysis of the fractured face requires a knowledge of not only normal anatomy, but also of . In these injuries, severe comminution of the face is present, and underlying skull injury is likely. 18 Mar Facial fracture management dates as early as Hippocratic era. Comminuted mandibular fractures are one of the challenging clinical condition requiring high surgi.